Provider Demographics
NPI:1205185063
Name:GOODMAN, DESIREE (MSPT, DPT)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MSPT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 GREENE AVE
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-2723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 GREENE AVE
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-2723
Practice Address - Country:US
Practice Address - Phone:631-256-6038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027065-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist