Provider Demographics
NPI:1013729987
Name:GOODMAN, CHARLENE MAY (MT)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:MAY
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1394 DANDELION WAY
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-0801
Mailing Address - Country:US
Mailing Address - Phone:808-358-7423
Mailing Address - Fax:
Practice Address - Street 1:1054 2ND ST
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5009
Practice Address - Country:US
Practice Address - Phone:858-901-7316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54658225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist