Provider Demographics
NPI:1417201765
Name:GOODALL, ELIZABETH J (PC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:J
Last Name:GOODALL
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 XENIA AVE
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-1836
Mailing Address - Country:US
Mailing Address - Phone:937-767-9171
Mailing Address - Fax:937-767-9175
Practice Address - Street 1:416 XENIA AVE
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1836
Practice Address - Country:US
Practice Address - Phone:937-767-9171
Practice Address - Fax:937-767-9171
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC-1100497101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health