Provider Demographics
NPI:1821374596
Name:GOODMAN, MICHELLE (BCBA)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-1811
Mailing Address - Country:US
Mailing Address - Phone:201-774-8545
Mailing Address - Fax:
Practice Address - Street 1:1036 WILSON AVE
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-1811
Practice Address - Country:US
Practice Address - Phone:201-774-8545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1-11-8456OtherBACB (BEHAVIOR ANALYST CERTIFICATION BOARD)