Provider Demographics
NPI:1376070417
Name:GOODMAN, DARYL ARNETT SR
Entity Type:Individual
Prefix:MR
First Name:DARYL
Middle Name:ARNETT
Last Name:GOODMAN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3212 FOWLER COURT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216
Mailing Address - Country:US
Mailing Address - Phone:704-451-9559
Mailing Address - Fax:
Practice Address - Street 1:3707 LATROBE DR STE 450
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1361
Practice Address - Country:US
Practice Address - Phone:704-563-3336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-19
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NCP0111471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)