Provider Demographics
NPI:1114587540
Name:GOODMAN, DAKOTA R (SAC-IT)
Entity Type:Individual
Prefix:
First Name:DAKOTA
Middle Name:R
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-9439
Mailing Address - Country:US
Mailing Address - Phone:608-768-4545
Mailing Address - Fax:
Practice Address - Street 1:2213 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-9439
Practice Address - Country:US
Practice Address - Phone:608-768-4545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18868-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)