Provider Demographics
NPI:1598847931
Name:GOODMAN, DINA P (LAC)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:P
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 19TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703
Mailing Address - Country:US
Mailing Address - Phone:701-858-0115
Mailing Address - Fax:
Practice Address - Street 1:6301 19TH AVE NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703
Practice Address - Country:US
Practice Address - Phone:701-858-0115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1400101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND75001Medicaid
ND26953OtherBLUE SHIELD OF ND