Provider Demographics
NPI:1275080541
Name:GOODGAME, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:GOODGAME
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 1:109 AUSTIN WAY
Mailing Address - Street 2:109 AUSTIN WAY
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-6207
Mailing Address - Country:US
Mailing Address - Phone:912-659-3379
Mailing Address - Fax:
Practice Address - Street 1:109 AUSTIN WAY
Practice Address - Street 2:109 AUSTIN WAY
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-6207
Practice Address - Country:US
Practice Address - Phone:912-659-3379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-05
Last Update Date:2016-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 685087163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)