Provider Demographics
NPI:1346367729
Name:GOODMAN, MARIE THERESA (COTA)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:THERESA
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:THERESA
Other - Last Name:LEONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:341 CHESTNUT HILL RD
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-7648
Mailing Address - Country:US
Mailing Address - Phone:401-792-9072
Mailing Address - Fax:
Practice Address - Street 1:2600 MENDON RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-3726
Practice Address - Country:US
Practice Address - Phone:401-658-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOTA00031224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIOTA00031OtherRHODE ISLAND LICENSE
RIMG42655Medicare ID - Type UnspecifiedMEDICARE