Provider Demographics
NPI:1336717362
Name:GOOD, ERIC WAYNE
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:WAYNE
Last Name:GOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 HARRISONVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-5141
Mailing Address - Country:US
Mailing Address - Phone:740-464-8768
Mailing Address - Fax:
Practice Address - Street 1:1125 KENT ST APT 10L
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2570
Practice Address - Country:US
Practice Address - Phone:740-250-3641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OHCDCA.183213101YA0400X
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)