Provider Demographics
NPI:1023566023
Name:GOODIN, RAY TRAVIS
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:TRAVIS
Last Name:GOODIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 WYANDOTTE ST
Mailing Address - Street 2:# 17
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-6471
Mailing Address - Country:US
Mailing Address - Phone:313-433-7330
Mailing Address - Fax:
Practice Address - Street 1:2625 WYANDOTTE ST
Practice Address - Street 2:# 17
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-6471
Practice Address - Country:US
Practice Address - Phone:313-433-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician