Provider Demographics
NPI:1124884242
Name:GOODMAN, TYLER WADE
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:WADE
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GRAND MENTAL HEALTH 407 S AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-5443
Mailing Address - Country:US
Mailing Address - Phone:580-485-5796
Mailing Address - Fax:
Practice Address - Street 1:93 NOEL LN
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-5443
Practice Address - Country:US
Practice Address - Phone:580-485-5796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist