Provider Demographics
NPI:1558663021
Name:GOODIN, TINA H (PH D)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:H
Last Name:GOODIN
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:GOODIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:600 SANDTREE DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33403-1597
Mailing Address - Country:US
Mailing Address - Phone:561-301-1464
Mailing Address - Fax:561-828-9272
Practice Address - Street 1:345 JUPITER LAKES BLVD STE 302A
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7100
Practice Address - Country:US
Practice Address - Phone:561-301-1464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-03
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8096103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFC278AMedicare PIN