MEDICARE: MARK GOODMAN LCSW

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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor
3	1041C0700X	Clinical Social Worker	5447	OR

General Provider Information

NPI Number	:	1568749687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK GOODMAN LCSW

Provider Business Mailing Address
First Line	:	399 E 10TH AVE
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97401-3380
Country	:	US
Telephone Number	:	541-868-2004
Fax Number	:

Provider Business Practice Location Address
First Line	:	62930 O B RILEY RD STE 200
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97703-9459
Country	:	US
Telephone Number	:	541-330-1919
Fax Number	:

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

Provider Enumeration Date	:	11/03/2011
Last Update Date	:	05/06/2022

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