Provider Demographics
NPI:1790111862
Name:GOODMAN, GRACE (PSYD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 S G ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3320
Mailing Address - Country:US
Mailing Address - Phone:909-382-7100
Mailing Address - Fax:909-382-7101
Practice Address - Street 1:250 S G ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3320
Practice Address - Country:US
Practice Address - Phone:909-382-7100
Practice Address - Fax:909-382-7101
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-20
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28905103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical