Provider Demographics
NPI:1891045274
Name:GOOLSBY, MICHELLE LYNN (MED)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNN
Last Name:GOOLSBY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10822 BLUE SKY DRIVE
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130
Mailing Address - Country:US
Mailing Address - Phone:405-259-9548
Mailing Address - Fax:
Practice Address - Street 1:10822 BLUE SKY DRIVE
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130
Practice Address - Country:US
Practice Address - Phone:405-259-9548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst