Provider Demographics
NPI:1962653444
Name:GOODMAN, PETER BERTRAM (LCSW, MSW)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:BERTRAM
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:LCSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4316 BRADFORD RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:EFLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27243-9467
Mailing Address - Country:US
Mailing Address - Phone:919-733-6355
Mailing Address - Fax:919-715-8043
Practice Address - Street 1:DOROTHEA DIX HOSPITAL
Practice Address - Street 2:3601 MAIL SERVICE CENTER
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27699-0001
Practice Address - Country:US
Practice Address - Phone:919-733-6355
Practice Address - Fax:919-715-8043
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0006971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical