Provider Demographics
NPI:1043515984
Name:GOODMAN, KELLEY (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 HOLLAND AVE
Mailing Address - Street 2:STRATTON VA MEDICAL CENTER
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3410
Mailing Address - Country:US
Mailing Address - Phone:518-626-6843
Mailing Address - Fax:
Practice Address - Street 1:113 HOLLAND AVE
Practice Address - Street 2:STRATTON VA MEDICAL CENTER
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3410
Practice Address - Country:US
Practice Address - Phone:518-626-6843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0659891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical