Provider Demographics
NPI:1003241282
Name:GOFORTH, TERRY LYNN
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:LYNN
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38722 SW DENT RD
Mailing Address - Street 2:
Mailing Address - City:WILLAMINA
Mailing Address - State:OR
Mailing Address - Zip Code:97396-9749
Mailing Address - Country:US
Mailing Address - Phone:503-876-3072
Mailing Address - Fax:
Practice Address - Street 1:38722 SW DENT RD
Practice Address - Street 2:
Practice Address - City:WILLAMINA
Practice Address - State:OR
Practice Address - Zip Code:97396-9749
Practice Address - Country:US
Practice Address - Phone:503-876-3072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst