Healthcare Provider Details

I. General information

NPI: 1003342478
Provider Name (Legal Business Name): BOBBY JOE GOODMAN M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2017
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 DELMAR BLVD STE B300
SAINT LOUIS MO
63112-3078
US

IV. Provider business mailing address

5501 DELMAR BLVD STE B300
SAINT LOUIS MO
63112-3078
US

V. Phone/Fax

Practice location:
  • Phone: 314-469-4908
  • Fax:
Mailing address:
  • Phone: 314-469-4908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: