MEDICARE: MR. DARYL ARNETT GOODMAN SR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	1041C0700X	Clinical Social Worker	P011147	NC

General Provider Information

NPI Number	:	1376070417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DARYL ARNETT GOODMAN SR.

Provider Business Mailing Address
First Line	:	3212 FOWLER COURT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216
Country	:	US
Telephone Number	:	704-451-9559
Fax Number	:

Provider Business Practice Location Address
First Line	:	3707 LATROBE DR STE 450
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-1361
Country	:	US
Telephone Number	:	704-563-3336
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2017
Last Update Date	:	05/19/2017

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