Provider Demographics
NPI:1205934676
Name:GOODMAN-FISCHTROM, BARBARA SUE (LICSW,LMFT,LADC)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:SUE
Last Name:GOODMAN-FISCHTROM
Suffix:
Gender:F
Credentials:LICSW,LMFT,LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11812 WAYZATA BLVD
Mailing Address - Street 2:SUITE # 120
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-2012
Mailing Address - Country:US
Mailing Address - Phone:952-288-5335
Mailing Address - Fax:
Practice Address - Street 1:11812 WAYZATA BLVD
Practice Address - Street 2:SUITE # 120
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2012
Practice Address - Country:US
Practice Address - Phone:952-288-5335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2270104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN090758800Medicaid