Basic Information
| Provider Information | |||||||||
| NPI: | 1740743319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIXON | ||||||||
| FirstName: | CALEB | ||||||||
| MiddleName: | GOODMAN | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25608 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063204476 | ||||||||
| FaxNumber: | 2065687043 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 5TH AVE STE P100 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981043176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063203351 | ||||||||
| FaxNumber: | 2065547787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2019 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY61131091 | WA | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | PY61131091 | WA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1740743319 | 05 | WA | MEDICAID |