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General NPI Number Information
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NPI Number | 1811587975
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Entity Type | Individual
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Provider Name | TAMARA LEA GOODMAN LMHC
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Gender | Female
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Dates
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Enumeration Date | 01/22/2021
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Last Update Date | 01/22/2021
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Provider Practice Location Address
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Address Line | 3810 COLDWATER RD
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City | FORT WAYNE
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State | IN
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Zip | 46805-1102
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Country | US
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Telephone | 260-460-1456
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Fax |
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Provider Business Mailing Address
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Address Line | 100 BLACKSMITH XING
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City | WATERLOO
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State | IN
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Zip | 46793-0090
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Country | US
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Telephone | 260-610-0389
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 87000356A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 39001925A
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License Number State | IN
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