Provider Demographics
NPI:1821596909
Name:GOODMAN, ROBERT LELAND
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LELAND
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 W. NORTH AVE, SECOND FLOOR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53205
Mailing Address - Country:US
Mailing Address - Phone:414-467-8884
Mailing Address - Fax:
Practice Address - Street 1:1134 W. NORTH AVE, SECOND FLOOR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205
Practice Address - Country:US
Practice Address - Phone:414-467-8884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18222-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)