Provider Demographics
NPI:1821898222
Name:GOODLOE, MYSTA
Entity type:Individual
Prefix:
First Name:MYSTA
Middle Name:
Last Name:GOODLOE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 CRYSTAL SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:NC
Mailing Address - Zip Code:27504-8695
Mailing Address - Country:US
Mailing Address - Phone:336-934-2311
Mailing Address - Fax:336-934-2311
Practice Address - Street 1:1786 METROMEDICAL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3861
Practice Address - Country:US
Practice Address - Phone:910-778-2109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-14
Last Update Date:2025-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-24-368240106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician