Provider Demographics
NPI:1437665189
Name:GOODSON, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GOODSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LINCOLN BEHAVIORAL SERVICES
Mailing Address - Street 2:9315 TELEGRAPH ROAD
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239
Mailing Address - Country:US
Mailing Address - Phone:313-450-4500
Mailing Address - Fax:
Practice Address - Street 1:LINCOLN BEHAVIORAL SERVICES
Practice Address - Street 2:9315 TELEGRAPH ROAD
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239
Practice Address - Country:US
Practice Address - Phone:313-450-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP613469067450Medicaid