Basic Information
Provider Information | |||||||||
NPI: | 1669915252 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOODON | ||||||||
FirstName: | MARION | ||||||||
MiddleName: | STEVE | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | IADC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DIRKS | ||||||||
OtherFirstName: | STEVE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | IADC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 800 5TH ST | ||||||||
Address2: |   | ||||||||
City: | SIOUX CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 511011317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7122342300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 800 5TH ST | ||||||||
Address2: |   | ||||||||
City: | SIOUX CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 511011317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7122342300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2016 | ||||||||
LastUpdateDate: | 11/30/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 16004 | IA | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.