Provider Demographics
NPI:1265683403
Name:GOODSPEED, TRACIE B (MED, LPC)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:B
Last Name:GOODSPEED
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3941 S 1ST ST W
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-8915
Mailing Address - Country:US
Mailing Address - Phone:918-687-3730
Mailing Address - Fax:
Practice Address - Street 1:1305 S COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-7802
Practice Address - Country:US
Practice Address - Phone:918-668-5588
Practice Address - Fax:918-686-6885
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool