Provider Demographics
NPI:1750942157
Name:GOODMAN, MARY JOANNE (CSW, SAC-IT)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JOANNE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:CSW, SAC-IT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JOANNE
Other - Last Name:FRITSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2842 S BUSINESS DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-6518
Mailing Address - Country:US
Mailing Address - Phone:920-458-6527
Mailing Address - Fax:920-458-6623
Practice Address - Street 1:2842 S BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-6518
Practice Address - Country:US
Practice Address - Phone:920-458-6527
Practice Address - Fax:920-458-6623
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18913-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100013835Medicaid