Provider Demographics
NPI:1427275924
Name:GOODNER, RICKY LEON (LMSW-ACP)
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:LEON
Last Name:GOODNER
Suffix:
Gender:M
Credentials:LMSW-ACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:COMANCHE
Mailing Address - State:TX
Mailing Address - Zip Code:76442-0847
Mailing Address - Country:US
Mailing Address - Phone:254-879-4900
Mailing Address - Fax:254-879-4990
Practice Address - Street 1:10201 HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:COMANCHE
Practice Address - State:TX
Practice Address - Zip Code:76442-4462
Practice Address - Country:US
Practice Address - Phone:254-879-4900
Practice Address - Fax:254-879-4990
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX155751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX15575OtherLICENSE