Provider Demographics
NPI:1902866304
Name:GOODMAN, PENNY (LCSW)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10645 N TATUM BLVD STE 200-370
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3068
Mailing Address - Country:US
Mailing Address - Phone:480-810-9020
Mailing Address - Fax:
Practice Address - Street 1:10645 N TATUM BLVD STE 200-370
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3068
Practice Address - Country:US
Practice Address - Phone:480-810-9020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-29261041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ736720Medicaid
AZ736720Medicaid