Basic Information
| Provider Information | |||||||||
| NPI: | 1770654360 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOFTON | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 PARKSIDE AVE NW | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495343411 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3285 122ND AVE | ||||||||
| Address2: | |||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490109511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696736617 | ||||||||
| FaxNumber: | 2696732738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 1041C0700X | 6801085687 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.