Provider Demographics
NPI:1467719914
Name:GOODMAN, NICOLE MICHELLE
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MICHELLE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 BEX CT APT B3
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3372
Mailing Address - Country:US
Mailing Address - Phone:757-769-1994
Mailing Address - Fax:
Practice Address - Street 1:244 BEX CT APT B3
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3372
Practice Address - Country:US
Practice Address - Phone:757-769-1994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst