Provider Demographics
NPI:1881098408
Name:GOODMAN, SUSAN MARY (MS, BCBA)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARY
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1703
Mailing Address - Country:US
Mailing Address - Phone:845-988-0155
Mailing Address - Fax:
Practice Address - Street 1:22 PARK AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-1703
Practice Address - Country:US
Practice Address - Phone:845-988-0155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist