Provider Demographics
NPI:1154030401
Name:CRICK-GOODMAN, MISTY MARIE (LE)
Entity type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:MARIE
Last Name:CRICK-GOODMAN
Suffix:
Gender:F
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20622 108TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-7969
Mailing Address - Country:US
Mailing Address - Phone:253-332-3173
Mailing Address - Fax:
Practice Address - Street 1:20622 108TH STREET CT E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-7969
Practice Address - Country:US
Practice Address - Phone:253-332-3173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9756246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty