Individual
TERRY GOODSPEED
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
3751 W MAIN ST, INDEPENDENCE, KS 67301-8446
(620) 331-1748
Mailing address
PO BOX 688, INDEPENDENCE, KS 67301-0688
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
LCAC 300
KS
1041C0700X
Clinical Social Worker
Primary
1903
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
069573
MEDICARE PTAN
KS
05
—
100322170B
—
KS
Enumeration date
09/02/2006
Last updated
12/01/2014
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