Provider Demographics
NPI:1396061198
Name:GOODALL, KRISTINA C
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:C
Last Name:GOODALL
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 1:1500 HIGHWAY 17 N
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-6081
Mailing Address - Country:US
Mailing Address - Phone:843-333-8624
Mailing Address - Fax:
Practice Address - Street 1:1500 HIGHWAY 17 N
Practice Address - Street 2:SUITE 104
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-6081
Practice Address - Country:US
Practice Address - Phone:843-333-8624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5728101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid