1396091740 NPI number — MS. DEMITRA JAMETTE GOODLOE MA LPC

Table of content: MS. DEMITRA JAMETTE GOODLOE MA LPC (NPI 1396091740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396091740 NPI number — MS. DEMITRA JAMETTE GOODLOE MA LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODLOE
Provider First Name:
DEMITRA
Provider Middle Name:
JAMETTE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396091740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2055 S IOLA CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80014-1027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-331-9077
Provider Business Mailing Address Fax Number:
303-780-9192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1133 LINCOLN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80203-2110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-832-6622
Provider Business Practice Location Address Fax Number:
303-863-0705
Provider Enumeration Date:
08/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LPC-11706 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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