Provider Demographics
NPI:1235263112
Name:GOODMAN, PETER ROBERT (LCSW, BCD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:ROBERT
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 FOX POND
Mailing Address - Street 2:
Mailing Address - City:SPRING HOUSE
Mailing Address - State:PA
Mailing Address - Zip Code:19477-1109
Mailing Address - Country:US
Mailing Address - Phone:215-290-1278
Mailing Address - Fax:302-655-8978
Practice Address - Street 1:20B TROLLEY SQ
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-3350
Practice Address - Country:US
Practice Address - Phone:302-658-5652
Practice Address - Fax:302-655-8978
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ100001771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical