Healthcare Provider Details

I. General information

NPI: 1992976740
Provider Name (Legal Business Name): DEBORAH GOODMAN MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 LAKE ST NE
WISE VA
24293-7919
US

IV. Provider business mailing address

628 LAKE ST NE
WISE VA
24293-7919
US

V. Phone/Fax

Practice location:
  • Phone: 276-328-8017
  • Fax: 276-328-3350
Mailing address:
  • Phone: 276-328-3350
  • Fax: 276-328-8017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number09120829
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: