Provider Demographics
NPI:1104577162
Name:GOODING, CHARLES RANDALL (SUDP)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RANDALL
Last Name:GOODING
Suffix:
Gender:M
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23830 PACIFIC HWY S STE 202A
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-7706
Mailing Address - Country:US
Mailing Address - Phone:206-501-5295
Mailing Address - Fax:
Practice Address - Street 1:23830 PACIFIC HWY S STE 202A
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-7706
Practice Address - Country:US
Practice Address - Phone:206-501-5295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60474403101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)