Provider Demographics
NPI:1831269448
Name:GOODMAN, ROBERTA R (LPAT)
Entity type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:R
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:LPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1111
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-1111
Mailing Address - Country:US
Mailing Address - Phone:505-988-3686
Mailing Address - Fax:505-310-1576
Practice Address - Street 1:187 TESUQUE VILLAGE RD
Practice Address - Street 2:
Practice Address - City:TESUQUE
Practice Address - State:NM
Practice Address - Zip Code:87506
Practice Address - Country:US
Practice Address - Phone:505-988-3686
Practice Address - Fax:505-310-1576
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0438101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health