Provider Demographics
NPI:1528403011
Name:GOODMAN, LISA MICHELLE
Entity Type:Individual
Prefix:
First Name:LISA
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 1:111 BELLE MEADE CT
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:NC
Mailing Address - Zip Code:27504-9268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 BELLE MEADE CT
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:NC
Practice Address - Zip Code:27504-9268
Practice Address - Country:US
Practice Address - Phone:919-894-1102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6968235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist