Provider Demographics
NPI:1609390830
Name:GOODMAN, MIRIAM ELANA IKEN
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:ELANA IKEN
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 1:8 COTTAGE RD
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-4406
Mailing Address - Country:US
Mailing Address - Phone:508-740-6486
Mailing Address - Fax:
Practice Address - Street 1:150 GROSSMAN DR STE 404
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4952
Practice Address - Country:US
Practice Address - Phone:508-740-6486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-30
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1343641041C0700X
MA1223821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical