Provider Demographics
NPI:1558539619
Name:GOODMAN, WENDY (LMHC, LADAC, LPCC)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:LMHC, LADAC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2859 PLAZA ROJO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-6521
Mailing Address - Country:US
Mailing Address - Phone:505-474-6825
Mailing Address - Fax:505-474-6825
Practice Address - Street 1:2859 PLAZA ROJO
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-6521
Practice Address - Country:US
Practice Address - Phone:505-474-6825
Practice Address - Fax:505-474-6825
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2011-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0122491101YA0400X
NM0111261101YM0800X
NM0127551101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1558539619Medicaid