Basic Information
Provider Information | |||||||||
NPI: | 1346222130 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOODENOW | ||||||||
FirstName: | LAWRENCE | ||||||||
MiddleName: | HOWARD | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 401 S BALLENGER HWY | ||||||||
Address2: |   | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485323638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8103421000 | ||||||||
FaxNumber: | 8103421590 | ||||||||
Practice Location | |||||||||
Address1: | 4448 OAKBRIDGE DR | ||||||||
Address2: |   | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485325494 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8103425333 | ||||||||
FaxNumber: | 8103421590 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2005 | ||||||||
LastUpdateDate: | 06/12/2010 | ||||||||
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 | 103TC0700X | 6301006703 | MI | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 01002469 | 01 | MI | HEALTH PLUS OF MI | OTHER | 1306896956 | 01 |   | LIST SERVICES GROUP NPI | OTHER | 680B512650 | 01 |   | BCBSM-BCN-FEP | OTHER | 1962541318 | 01 |   | MCLAREN PHD GROUP NPI # | OTHER | G96288055 | 01 |   | LIST SERVICES MEDICARE ID | OTHER | 1018118 | 01 | MI | MCLAREN HEALTH ADVANTAGE | OTHER | 056350 | 01 |   | VALUE OPTIONS | OTHER | 1018118 | 01 | MI | MCLAREN HEALTH PLAN | OTHER |