Provider Demographics
NPI:1265632756
Name:GOODEN, CYNDEE
Entity Type:Individual
Prefix:
First Name:CYNDEE
Middle Name:
Last Name:GOODEN
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:PO BOX 1364
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-1364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:390 E PARKCENTER BLVD
Practice Address - Street 2:STE 130
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6662
Practice Address - Country:US
Practice Address - Phone:208-433-9211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2012-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1265632756Medicaid
ID1265632756Medicaid