Healthcare Provider Details

I. General information

NPI: 1720481880
Provider Name (Legal Business Name): SHEILA F GOODMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2014
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2766 W 11 MILE RD
BERKLEY MI
48072-3033
US

IV. Provider business mailing address

20948 SEMINOLE ST
SOUTHFIELD MI
48033-3552
US

V. Phone/Fax

Practice location:
  • Phone: 248-542-2424
  • Fax:
Mailing address:
  • Phone: 248-763-5847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703062554
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: