=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043684111
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNEMARIE GOODMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2015
-----------------------------------------------------
Last Update Date | 11/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10102 ROCKAWAY BLVD
-----------------------------------------------------
City | OZONE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11417-2229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-232-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7502 AUSTIN ST APT. 2B
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-6237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-852-3248
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 059772
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------