Provider Demographics
NPI:1972611788
Name:GOODRUM, STEPHANIE (LPC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GOODRUM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3772 HIGHWAY 45 S
Mailing Address - Street 2:
Mailing Address - City:SELMER
Mailing Address - State:TN
Mailing Address - Zip Code:38375-6606
Mailing Address - Country:US
Mailing Address - Phone:731-645-5753
Mailing Address - Fax:731-645-9885
Practice Address - Street 1:641 E POPLAR AVE
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-1828
Practice Address - Country:US
Practice Address - Phone:731-645-5753
Practice Address - Fax:731-645-9885
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC1677101YP2500X, 101YM0800X
TNLPC 1677104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4099873OtherBCBS PROVIDER NUMBER
TN572994000Medicaid