Individual
WALLACE GOODMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
501 HIGHWAY J N, HAYTI, MO 63851
(573) 359-2600
Mailing address
2009 SOUTHWIND CV, DYERSBURG, TN 38024-8875
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
2011024580
MO
Other
Enumeration date
11/18/2013
Last updated
11/18/2013
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