Provider Demographics
NPI:1083039101
Name:GOODSON, TARA
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:GOODSON
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 1:2064 HWY 27
Mailing Address - Street 2:
Mailing Address - City:WETUMKA
Mailing Address - State:OK
Mailing Address - Zip Code:74883
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1605 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-4022
Practice Address - Country:US
Practice Address - Phone:405-380-8033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional