Provider Demographics
NPI:1194156216
Name:GOODSON, KRISTY DIANE
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:DIANE
Last Name:GOODSON
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:PO BOX 2106
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2106
Mailing Address - Country:US
Mailing Address - Phone:208-523-5319
Mailing Address - Fax:
Practice Address - Street 1:1675 CURLEW DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4718
Practice Address - Country:US
Practice Address - Phone:208-523-5319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-30
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-383931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical