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General NPI Number Information
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NPI Number | 1609390830
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Entity Type | Individual
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Provider Name | MIRIAM ELANA IKEN GOODMAN
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Gender | Female
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Dates
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Enumeration Date | 07/30/2017
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Last Update Date | 12/18/2020
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Provider Practice Location Address
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Address Line | 150 GROSSMAN DR STE 404
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City | BRAINTREE
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State | MA
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Zip | 02184-4952
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Country | US
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Telephone | 508-740-6486
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Fax |
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Provider Business Mailing Address
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Address Line | 8 COTTAGE RD
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City | WAYLAND
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State | MA
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Zip | 01778-4406
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Country | US
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Telephone | 508-740-6486
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 134364
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 122382
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License Number State | MA
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