Provider Demographics
NPI:1689941569
Name:GOODE, ANDRE M (QBA)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:M
Last Name:GOODE
Suffix:
Gender:M
Credentials:QBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 E FLAMINGO RD # 577
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5263
Mailing Address - Country:US
Mailing Address - Phone:702-202-2040
Mailing Address - Fax:702-202-6551
Practice Address - Street 1:3430 E FLAMINGO RD STE 220
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5065
Practice Address - Country:US
Practice Address - Phone:702-202-2040
Practice Address - Fax:702-202-6551
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1073750626Medicaid