Provider Demographics
NPI:1689465676
Name:GOODFELLOW, DAWSEN J
Entity type:Individual
Prefix:
First Name:DAWSEN
Middle Name:J
Last Name:GOODFELLOW
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 1:1747 HERITAGE LN STE B101
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-8546
Mailing Address - Country:US
Mailing Address - Phone:801-896-0793
Mailing Address - Fax:
Practice Address - Street 1:1747 HERITAGE LN STE B101
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-8546
Practice Address - Country:US
Practice Address - Phone:801-896-0793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-16
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician