Provider Demographics
NPI:1932670130
Name:GOODMAN, JAIME (CPED)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MOSS RD
Mailing Address - Street 2:
Mailing Address - City:VOORHEESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12186-5042
Mailing Address - Country:US
Mailing Address - Phone:518-653-2355
Mailing Address - Fax:
Practice Address - Street 1:1659 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4050
Practice Address - Country:US
Practice Address - Phone:518-869-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCPED1770225000000X, 224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthistGroup - Single Specialty
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Single Specialty