Healthcare Provider Details

I. General information

NPI: 1003048885
Provider Name (Legal Business Name): REBECCA GOFFMAN LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9220 BASS LAKE RD STE 255
NEW HOPE MN
55428-3019
US

IV. Provider business mailing address

22426 SAINT FRANCIS BLVD
ANOKA MN
55303-9670
US

V. Phone/Fax

Practice location:
  • Phone: 763-225-4052
  • Fax:
Mailing address:
  • Phone: 763-753-7310
  • Fax: 763-753-6529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5120
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: