Basic Information
Provider Information | |||||||||
NPI: | 1700171600 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOODE | ||||||||
FirstName: | SONYA | ||||||||
MiddleName: | KAY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1960 | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724031960 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8709368000 | ||||||||
FaxNumber: | 8709343660 | ||||||||
Practice Location | |||||||||
Address1: | 2205 W PARKER RD | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724047778 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8709368000 | ||||||||
FaxNumber: | 8709343660 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2011 | ||||||||
LastUpdateDate: | 12/14/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 4090-C | AR | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 5GG13 | 01 | AR | BCBS | OTHER | 186975795 | 05 | AR |   | MEDICAID |