Provider Demographics
NPI:1003048885
Name:GOFFMAN, REBECCA (LP)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:GOFFMAN
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22426 SAINT FRANCIS BLVD
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-9670
Mailing Address - Country:US
Mailing Address - Phone:763-753-7310
Mailing Address - Fax:763-753-6529
Practice Address - Street 1:9220 BASS LAKE RD STE 255
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3019
Practice Address - Country:US
Practice Address - Phone:763-225-4052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5120103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical