Provider Demographics
NPI:1720824238
Name:GOODE, SAMUEL DENTON
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DENTON
Last Name:GOODE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E PORTLAND ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-1870
Mailing Address - Country:US
Mailing Address - Phone:417-920-7199
Mailing Address - Fax:
Practice Address - Street 1:500 W DANIELS ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-7322
Practice Address - Country:US
Practice Address - Phone:417-719-2057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORBT-24-359246106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician