Healthcare Provider Details

I. General information

NPI: 1831269448
Provider Name (Legal Business Name): ROBERTA R GOODMAN LPAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 05/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 TESUQUE VILLAGE RD
TESUQUE NM
87506
US

IV. Provider business mailing address

PO BOX 1111
SANTA FE NM
87504-1111
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-3686
  • Fax: 505-310-1576
Mailing address:
  • Phone: 505-988-3686
  • Fax: 505-310-1576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0438
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: