Provider Demographics
NPI:1326871583
Name:GOODSPEED, SHANIKA
Entity type:Individual
Prefix:
First Name:SHANIKA
Middle Name:
Last Name:GOODSPEED
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 1:585 GROVE ST STE 145
Mailing Address - Street 2:PMB 745
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4791
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:585 GROVE ST STE 145
Practice Address - Street 2:PMB 745
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4791
Practice Address - Country:US
Practice Address - Phone:703-982-0980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810008620103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical