Provider Demographics
NPI:1639131121
Name:GOUDY, TRACY JEAN (MA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:JEAN
Last Name:GOUDY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11580 NE BEVERLY DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-9538
Mailing Address - Country:US
Mailing Address - Phone:541-265-4508
Mailing Address - Fax:541-265-4508
Practice Address - Street 1:11580 NE BEVERLY DR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-9538
Practice Address - Country:US
Practice Address - Phone:541-265-4508
Practice Address - Fax:541-265-4508
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4248101YM0800X
OR94-R-13101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)