Provider Demographics
NPI:1942671292
Name:GOODMAN, KRISTINA (JD, MA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:JD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 WALNUT ST APT 5
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02108-1408
Mailing Address - Country:US
Mailing Address - Phone:917-756-9792
Mailing Address - Fax:
Practice Address - Street 1:12 WALNUT ST APT 5
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-1408
Practice Address - Country:US
Practice Address - Phone:917-756-9792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1705106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
042104356OtherEIN