Provider Demographics
NPI:1649380924
Name:GOODMAN, DAVID J (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1035 W GLEN OAKS LN STE 110
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3392
Mailing Address - Country:US
Mailing Address - Phone:262-244-6178
Mailing Address - Fax:262-299-3040
Practice Address - Street 1:W175N11081 STONEWOOD DR STE 212
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-4771
Practice Address - Country:US
Practice Address - Phone:262-244-6177
Practice Address - Fax:262-299-3040
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2581-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000084137OtherMEDICARE
WI39152500Medicaid