Healthcare Provider Details

I. General information

NPI: 1851370787
Provider Name (Legal Business Name): ROBERT GEORGE GOODMAN ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 FRANKLIN ST
WATERTOWN MA
02472-4020
US

IV. Provider business mailing address

83 FRANKLIN ST
WATERTOWN MA
02472-4020
US

V. Phone/Fax

Practice location:
  • Phone: 617-923-9988
  • Fax: 617-923-1361
Mailing address:
  • Phone: 617-923-9988
  • Fax: 617-923-1361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number4136
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: