Provider Demographics
NPI:1811028632
Name:GOODMAN, MARY ELIZABETH (MFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 CHABLIS DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-6691
Mailing Address - Country:US
Mailing Address - Phone:707-836-7778
Mailing Address - Fax:707-836-7778
Practice Address - Street 1:290 E GOBBI ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5559
Practice Address - Country:US
Practice Address - Phone:707-463-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37370106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist