Provider Demographics
NPI:1679668875
Name:GOODMAN, CARY K (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARY
Middle Name:K
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 SHERLEY PLACE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825
Mailing Address - Country:US
Mailing Address - Phone:203-576-1371
Mailing Address - Fax:
Practice Address - Street 1:2335 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825
Practice Address - Country:US
Practice Address - Phone:203-334-7411
Practice Address - Fax:203-372-7596
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2056103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060002056CT01OtherANTEHM BC BS
CT353667OtherMHN
CT004250370Medicaid