Provider Demographics
NPI:1114516820
Name:GOODKIN, CARLY
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:GOODKIN
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 1:10755 SCRIPPS POWAY PKWY UNIT 642
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-3924
Mailing Address - Country:US
Mailing Address - Phone:484-441-3309
Mailing Address - Fax:
Practice Address - Street 1:10755 SCRIPPS POWAY PKWY UNIT 642
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-6211
Practice Address - Country:US
Practice Address - Phone:484-441-3309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-16
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122284106H00000X
PAMF001270106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist