Provider Demographics
NPI:1982639803
Name:GOODMAN, DAVID WAYNE (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2639 SUNSET AVENUE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-3700
Mailing Address - Country:US
Mailing Address - Phone:252-937-4455
Mailing Address - Fax:252-937-3060
Practice Address - Street 1:2639 SUNSET AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3700
Practice Address - Country:US
Practice Address - Phone:252-937-4455
Practice Address - Fax:252-937-3060
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0852103TC1900X
IL072002957103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC03624OtherBCBSNC
NC6000021Medicaid
2818630Medicare ID - Type Unspecified