Provider Demographics
NPI:1427753532
Name:GOODRUM, CHARLOTTE GALE
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:GALE
Last Name:GOODRUM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:GALE
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:125 S MAIN CROSS ST
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-1065
Mailing Address - Country:US
Mailing Address - Phone:606-638-0938
Mailing Address - Fax:859-813-5394
Practice Address - Street 1:125 S MAIN CROSS ST
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1065
Practice Address - Country:US
Practice Address - Phone:606-638-0938
Practice Address - Fax:859-813-5394
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-31
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator