=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255468344
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHERYL LYNN GOODMAN PCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 02/07/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 OSUNA RD NE STE H4
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-5955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-345-2778
-----------------------------------------------------
Fax | 505-345-2878
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 124 SAN LUCAS
-----------------------------------------------------
City | BELEN
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87002-7011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-861-1144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | E0003856
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0101321
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------