Healthcare Provider Details

I. General information

NPI: 1255468344
Provider Name (Legal Business Name): CHERYL LYNN GOODMAN PCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 02/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 OSUNA RD NE STE H4
ALBUQUERQUE NM
87107-5955
US

IV. Provider business mailing address

124 SAN LUCAS
BELEN NM
87002-7011
US

V. Phone/Fax

Practice location:
  • Phone: 505-345-2778
  • Fax: 505-345-2878
Mailing address:
  • Phone: 505-861-1144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE0003856
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0101321
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: