MEDICARE: LAZIRA GOODMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-23-304833	SC

General Provider Information

NPI Number	:	1477326353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAZIRA GOODMAN

Provider Business Mailing Address
First Line	:	PO BOX 931142
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	31193-1142
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2460 INDIA HOOK RD STE 105
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-3531
Country	:	US
Telephone Number	:	803-366-6250
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2023
Last Update Date	:	11/02/2023

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