Provider Demographics
NPI:1982851200
Name:GOODSON, MARIE RALLIE (MS-CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:RALLIE
Last Name:GOODSON
Suffix:
Gender:F
Credentials:MS-CCC-SLP
Other - Prefix:
Other - First Name:RALLIE
Other - Middle Name:
Other - Last Name:LJUBA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:54885 AVENIDA CARRANZA
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-3745
Mailing Address - Country:US
Mailing Address - Phone:310-387-0740
Mailing Address - Fax:
Practice Address - Street 1:54885 AVENIDA CARRANZA
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-3745
Practice Address - Country:US
Practice Address - Phone:760-775-8160
Practice Address - Fax:760-775-8483
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP8945235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist