Healthcare Provider Details

I. General information

NPI: 1558539619
Provider Name (Legal Business Name): WENDY GOODMAN LMHC, LADAC, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 03/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2859 PLAZA ROJO
SANTA FE NM
87507-6521
US

IV. Provider business mailing address

2859 PLAZA ROJO
SANTA FE NM
87507-6521
US

V. Phone/Fax

Practice location:
  • Phone: 505-474-6825
  • Fax: 505-474-6825
Mailing address:
  • Phone: 505-474-6825
  • Fax: 505-474-6825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0122491
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0111261
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0127551
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: