Provider Demographics
NPI:1023899614
Name:GOODSON, SAMUEL L (BS, LMBT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:GOODSON
Suffix:
Gender:F
Credentials:BS, LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 BALLAST PT
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-6217
Mailing Address - Country:US
Mailing Address - Phone:919-698-4648
Mailing Address - Fax:
Practice Address - Street 1:120 E MAIN ST # 200
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-2448
Practice Address - Country:US
Practice Address - Phone:919-698-4648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20022172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist