Provider Demographics
NPI:1689918054
Name:GOFFNER, TANGY DENISE
Entity Type:Individual
Prefix:
First Name:TANGY
Middle Name:DENISE
Last Name:GOFFNER
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 1:1129 W MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-2914
Mailing Address - Country:US
Mailing Address - Phone:702-462-1893
Mailing Address - Fax:
Practice Address - Street 1:1129 W MONROE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2914
Practice Address - Country:US
Practice Address - Phone:702-462-1893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-24
Last Update Date:2012-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20121267098103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent