Provider Demographics
NPI:1912567793
Name:GOODMAN, MAURENE (MA)
Entity Type:Individual
Prefix:
First Name:MAURENE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 DUFFY AVE
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-3627
Mailing Address - Country:US
Mailing Address - Phone:516-417-1030
Mailing Address - Fax:
Practice Address - Street 1:300 GARDEN CITY PLZ STE 350
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-3358
Practice Address - Country:US
Practice Address - Phone:516-531-7210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1375822601OtherUNITED HEALTHCARE OXFORD