Provider Demographics
NPI:1013435890
Name:GOUDIE, SAMANTHA LYNNE (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNNE
Last Name:GOUDIE
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7250 NIGHTINGALE DR APT 12
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-9307
Mailing Address - Country:US
Mailing Address - Phone:319-850-6693
Mailing Address - Fax:
Practice Address - Street 1:6629 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1098
Practice Address - Country:US
Practice Address - Phone:419-517-1070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1700483104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker