Provider Demographics
NPI:1467136069
Name:GOODEN, STEPHEN ANTHONY
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ANTHONY
Last Name:GOODEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5939 TOOLEY ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-1332
Mailing Address - Country:US
Mailing Address - Phone:619-228-5049
Mailing Address - Fax:
Practice Address - Street 1:5939 TOOLEY ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-1332
Practice Address - Country:US
Practice Address - Phone:619-228-5049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician