Healthcare Provider Details

I. General information

NPI: 1134984941
Provider Name (Legal Business Name): LEAH GOODMAN LCSW, ACHP-SW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 TORTUGA BAY DR
SAINT AUGUSTINE FL
32092-3211
US

IV. Provider business mailing address

451 TORTUGA BAY DR
SAINT AUGUSTINE FL
32092-3211
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-4611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW20309
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: