Provider Demographics
NPI:1558455139
Name:GOODMAN, VANESSA RITA (LICSW)
Entity Type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:RITA
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 COLBY ROAD
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184
Mailing Address - Country:US
Mailing Address - Phone:781-223-8514
Mailing Address - Fax:
Practice Address - Street 1:28 COLBY ROAD
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184
Practice Address - Country:US
Practice Address - Phone:781-223-8514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1061921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1854089Medicaid
MAP20369Medicare ID - Type Unspecified