Provider Demographics
NPI:1811220692
Name:GOODEN, TASHA M
Entity Type:Individual
Prefix:MRS
First Name:TASHA
Middle Name:M
Last Name:GOODEN
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 1:650 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-4429
Mailing Address - Country:US
Mailing Address - Phone:918-587-9471
Mailing Address - Fax:918-560-1399
Practice Address - Street 1:6115 HICKORY GROVE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-4207
Practice Address - Country:US
Practice Address - Phone:704-532-4262
Practice Address - Fax:704-532-7617
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NC25979101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746170GMedicaid