Provider Demographics
NPI:1851482590
Name:GOODMAN, BEVERLY JEAN
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:JEAN
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:BEVERLY
Other - Middle Name:JEAN
Other - Last Name:BUTTERFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:106 VIA CANDELARIA
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-4145
Mailing Address - Country:US
Mailing Address - Phone:949-589-0128
Mailing Address - Fax:
Practice Address - Street 1:653 CAMINO DE LOS MARES
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2808
Practice Address - Country:US
Practice Address - Phone:949-496-0122
Practice Address - Fax:949-496-5027
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA475225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT475BMedicare ID - Type Unspecified