Provider Demographics
NPI:1225097116
Name:GOODELL, REBECCA MILDRED (RDLD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MILDRED
Last Name:GOODELL
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-4465
Mailing Address - Country:US
Mailing Address - Phone:507-373-1905
Mailing Address - Fax:
Practice Address - Street 1:404 W FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2437
Practice Address - Country:US
Practice Address - Phone:507-373-2384
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1126133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered