Provider Demographics
NPI:1336274398
Name:GOODMAN, KELRIC S (LCPC)
Entity Type:Individual
Prefix:
First Name:KELRIC
Middle Name:S
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 OELLA AVE
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5419
Mailing Address - Country:US
Mailing Address - Phone:443-851-3224
Mailing Address - Fax:
Practice Address - Street 1:419 OELLA AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-5419
Practice Address - Country:US
Practice Address - Phone:443-851-3224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1976101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD212150600Medicaid