Basic Information
Provider Information | |||||||||
NPI: | 1396091740 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOODLOE | ||||||||
FirstName: | DEMITRA | ||||||||
MiddleName: | JAMETTE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2055 S IOLA CT | ||||||||
Address2: |   | ||||||||
City: | AURORA | ||||||||
State: | CO | ||||||||
PostalCode: | 800141027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7203319077 | ||||||||
FaxNumber: | 3037809192 | ||||||||
Practice Location | |||||||||
Address1: | 1133 LINCOLN ST | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802032110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3038326622 | ||||||||
FaxNumber: | 3038630705 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2012 | ||||||||
LastUpdateDate: | 05/05/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 101YP2500X | LPC-11706 | CO | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.