Provider Demographics
NPI:1093331092
Name:GOODHART, KAITLYN LEE
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:LEE
Last Name:GOODHART
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 1:2160 HOWLAND WILSON RD NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-3921
Mailing Address - Country:US
Mailing Address - Phone:330-984-2361
Mailing Address - Fax:
Practice Address - Street 1:2160 HOWLAND WILSON RD NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-3921
Practice Address - Country:US
Practice Address - Phone:330-984-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health