Basic Information
| Provider Information | |||||||||
| NPI: | 1063993608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODFELLOW | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | LACHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUESCH | ||||||||
| OtherFirstName: | MEGAN | ||||||||
| OtherMiddleName: | LACHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16219 285TH STREET CT E | ||||||||
| Address2: | |||||||||
| City: | GRAHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983388700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533989428 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16219 285TH STREET CT E | ||||||||
| Address2: | |||||||||
| City: | GRAHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983388700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533989428 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2018 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LF61334437 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.