Provider Demographics
NPI:1497105464
Name:GOODMAN, ILIANA JESSICA (OTR/L, PAMS)
Entity Type:Individual
Prefix:
First Name:ILIANA
Middle Name:JESSICA
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:OTR/L, PAMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 E WAIPUILANI RD
Mailing Address - Street 2:UNIT A
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-8219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:472 KAULANA ST
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-2050
Practice Address - Country:US
Practice Address - Phone:808-877-7840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1507225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist