Provider Demographics
NPI:1780383646
Name:GOODEN, ANDRIA
Entity type:Individual
Prefix:
First Name:ANDRIA
Middle Name:
Last Name:GOODEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 W MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2943
Mailing Address - Country:US
Mailing Address - Phone:313-344-9099
Mailing Address - Fax:
Practice Address - Street 1:TEAM WELLNESS CENTER
Practice Address - Street 2:2925 RUSSELL ST
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207
Practice Address - Country:US
Practice Address - Phone:313-396-5300
Practice Address - Fax:313-379-1043
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist