Provider Demographics
NPI:1134348329
Name:GOODALL, EDWIN BAKER III (PHD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:BAKER
Last Name:GOODALL
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 134
Mailing Address - Street 2:
Mailing Address - City:CENTER SANDWICH
Mailing Address - State:NH
Mailing Address - Zip Code:03227-0134
Mailing Address - Country:US
Mailing Address - Phone:603-284-7174
Mailing Address - Fax:603-528-2257
Practice Address - Street 1:401 GILFORD AVE
Practice Address - Street 2:UNIT 103
Practice Address - City:GILFORD
Practice Address - State:NH
Practice Address - Zip Code:03249-7500
Practice Address - Country:US
Practice Address - Phone:603-496-7955
Practice Address - Fax:603-528-2257
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH196103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0602256YONHO1OtherANTHEM BCBS
NH80622256Medicaid
NH80622256Medicaid