Basic Information
| Provider Information | |||||||||
| NPI: | 1114179322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOFF | ||||||||
| FirstName: | WASSAN | ||||||||
| MiddleName: | COOK | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LSCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4101 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660485014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136822000 | ||||||||
| FaxNumber: | 9137584149 | ||||||||
| Practice Location | |||||||||
| Address1: | 4101 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660485014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136822000 | ||||||||
| FaxNumber: | 9137584149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 11/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 5075 | KS | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 4112 | KS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.