Provider Demographics
NPI:1891035614
Name:GOODMAN, SUE
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 MARLBERRY PL
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-7475
Mailing Address - Country:US
Mailing Address - Phone:313-732-7332
Mailing Address - Fax:702-388-4358
Practice Address - Street 1:667 MARLBERRY PL
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7475
Practice Address - Country:US
Practice Address - Phone:313-732-7332
Practice Address - Fax:702-388-4358
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV104100000X, 101Y00000X, 101YA0400X, 101YM0800X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101066Medicaid
LA101066Medicaid
OH101066Medicaid
TX101066Medicaid
CA101066Medicaid
GA101066Medicaid
AZ101066Medicaid
IL101066Medicaid
NV101066Medicaid
TN101066Medicaid
FL101066Medicaid