Provider Demographics
NPI:1639664923
Name:GOODE, KRYSTALYN (SAC-IT)
Entity Type:Individual
Prefix:MS
First Name:KRYSTALYN
Middle Name:
Last Name:GOODE
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 N WEIL STREET
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3060
Mailing Address - Country:US
Mailing Address - Phone:414-962-1200
Mailing Address - Fax:414-962-2305
Practice Address - Street 1:2625 N WEIL STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212
Practice Address - Country:US
Practice Address - Phone:414-962-1200
Practice Address - Fax:414-962-2305
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
18439-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)