Provider Demographics
NPI:1467668889
Name:GOUDY, TONY (PHD)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:GOUDY
Suffix:
Gender:M
Credentials:PHD
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 129
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-0129
Mailing Address - Country:US
Mailing Address - Phone:304-473-8988
Mailing Address - Fax:304-472-9849
Practice Address - Street 1:RT 4 & 20 SOUTH
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ROCK CAVE
Practice Address - State:WV
Practice Address - Zip Code:26234
Practice Address - Country:US
Practice Address - Phone:304-924-9081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV671103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0164853000Medicaid