Provider Demographics
NPI:1629470620
Name:GOODMAN, REVITAL (LCSW)
Entity Type:Individual
Prefix:
First Name:REVITAL
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9858 GLADES RD # D3-218
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-3983
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9858 GLADES RD # D3-218
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-3983
Practice Address - Country:US
Practice Address - Phone:323-770-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 11854171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor