Provider Demographics
NPI:1811251556
Name:GOODMAN, ROBERTA (PHD)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 S HASTINGS WAY
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3426
Mailing Address - Country:US
Mailing Address - Phone:715-834-3171
Mailing Address - Fax:715-834-3174
Practice Address - Street 1:826 S HASTINGS WAY
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3426
Practice Address - Country:US
Practice Address - Phone:715-834-3171
Practice Address - Fax:715-834-3174
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2545-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist