Healthcare Provider Details

I. General information

NPI: 1750802526
Provider Name (Legal Business Name): TIFFANY GOODMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIFFANY PATRICE PERRY

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 N 25TH ST BSMT
RICHMOND VA
23223-6539
US

IV. Provider business mailing address

719 N 25TH ST BSMT
RICHMOND VA
23223-6539
US

V. Phone/Fax

Practice location:
  • Phone: 804-643-0002
  • Fax:
Mailing address:
  • Phone: 804-643-0002
  • 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 Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: