Provider Demographics
NPI:1659997575
Name:GOSS, CA LITRA LYNNETTE
Entity Type:Individual
Prefix:
First Name:CA LITRA
Middle Name:LYNNETTE
Last Name:GOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6109 N 12TH ST UNIT 8
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-1716
Mailing Address - Country:US
Mailing Address - Phone:602-877-6686
Mailing Address - Fax:
Practice Address - Street 1:2420 W ECHO LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4856
Practice Address - Country:US
Practice Address - Phone:602-877-6686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
AZ320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No253Z00000XAgenciesIn Home Supportive Care