Provider Demographics
NPI:1679277099
Name:GODERUM, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:GODERUM
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 1:2720 HIDDEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-1828
Mailing Address - Country:US
Mailing Address - Phone:707-328-7513
Mailing Address - Fax:
Practice Address - Street 1:2720 HIDDEN VALLEY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-1828
Practice Address - Country:US
Practice Address - Phone:707-328-7513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor