Provider Demographics
NPI:1184865347
Name:GOODMAN, REGINA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10850 W PARK PL STE 100
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-3636
Mailing Address - Country:US
Mailing Address - Phone:262-542-3255
Mailing Address - Fax:414-359-1021
Practice Address - Street 1:10850 W PARK PL STE 100
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-3636
Practice Address - Country:US
Practice Address - Phone:262-542-3255
Practice Address - Fax:414-359-1021
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7499-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical