Provider Demographics
NPI:1821211939
Name:GOODEN, STACY MARIE (MA)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:MARIE
Last Name:GOODEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 D ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-3104
Mailing Address - Country:US
Mailing Address - Phone:304-720-3835
Mailing Address - Fax:304-720-3836
Practice Address - Street 1:218 D ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-3104
Practice Address - Country:US
Practice Address - Phone:304-720-3835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2189101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional