Provider Demographics
NPI:1407047632
Name:GOODMAN, PHILIP J (LCSW)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:J
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-2048
Mailing Address - Country:US
Mailing Address - Phone:859-253-1993
Mailing Address - Fax:859-255-1134
Practice Address - Street 1:1310 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-2048
Practice Address - Country:US
Practice Address - Phone:859-253-1993
Practice Address - Fax:859-255-1134
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical