Provider Demographics
NPI:1255468344
Name:GOODMAN, CHERYL LYNN (PCC)
Entity type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:LYNN
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SAN LUCAS
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-7011
Mailing Address - Country:US
Mailing Address - Phone:505-861-1144
Mailing Address - Fax:
Practice Address - Street 1:320 OSUNA RD NE STE H4
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5955
Practice Address - Country:US
Practice Address - Phone:505-345-2778
Practice Address - Fax:505-345-2878
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2009-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0003856101YM0800X
NM0101321101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health