Provider Demographics
NPI:1710554159
Name:GOODMAN, KIM WENDEE
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:WENDEE
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 1:17111 BEACH BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-5947
Mailing Address - Country:US
Mailing Address - Phone:714-654-1570
Mailing Address - Fax:844-533-6952
Practice Address - Street 1:17111 BEACH BLVD STE 205
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5947
Practice Address - Country:US
Practice Address - Phone:714-654-1570
Practice Address - Fax:844-533-6952
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA252751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty