Healthcare Provider Details

I. General information

NPI: 1083271001
Provider Name (Legal Business Name): SUZANNE GOODWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 W RIDGEWOOD AVE
RIDGEWOOD NJ
07450-3199
US

IV. Provider business mailing address

88 W RIDGEWOOD AVE
RIDGEWOOD NJ
07450-3199
US

V. Phone/Fax

Practice location:
  • Phone: 914-589-6629
  • Fax: 914-589-6629
Mailing address:
  • Phone: 914-589-6629
  • Fax: 914-589-6629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number000994-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: