Healthcare Provider Details

I. General information

NPI: 1922945112
Provider Name (Legal Business Name): ELI JUSTIN GOODMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 DUCKWOOD DR STE 500
EAGAN MN
55122-1399
US

IV. Provider business mailing address

2044 OAKDALE AVE APT 105
WEST ST PAUL MN
55118-4671
US

V. Phone/Fax

Practice location:
  • Phone: 612-440-7250
  • Fax:
Mailing address:
  • Phone: 763-354-9591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11305
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: