Provider Demographics
NPI:1962027797
Name:REGINA GOODMAN, L.C.S.W., LLC
Entity Type:Organization
Organization Name:REGINA GOODMAN, L.C.S.W., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:414-828-3634
Mailing Address - Street 1:777 N JEFFERSON ST STE 402
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3713
Mailing Address - Country:US
Mailing Address - Phone:414-502-9245
Mailing Address - Fax:
Practice Address - Street 1:777 N JEFFERSON ST STE 402
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3713
Practice Address - Country:US
Practice Address - Phone:414-502-9245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-08
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42184700Medicaid