Provider Demographics
NPI:1538667332
Name:GOODMAN, MORGAN
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:
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 1:3769 QUARTON RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-4058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3769 QUARTON RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-4058
Practice Address - Country:US
Practice Address - Phone:248-894-1966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other