Provider Demographics
NPI:1265957914
Name:GOODEN, DE'RESE ZYIRE (NCC, LCMHC, CCHT)
Entity type:Individual
Prefix:MR
First Name:DE'RESE
Middle Name:ZYIRE
Last Name:GOODEN
Suffix:
Gender:M
Credentials:NCC, LCMHC, CCHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-2070
Mailing Address - Country:US
Mailing Address - Phone:937-860-1038
Mailing Address - Fax:270-203-0587
Practice Address - Street 1:31 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2070
Practice Address - Country:US
Practice Address - Phone:937-860-1038
Practice Address - Fax:270-203-0587
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2025-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
OHC.1700611101YP2500X, 405300000X
OH11725102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0307155Medicaid