MEDICARE: MARLA GOODMAN

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1528634037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLA GOODMAN

Provider Business Mailing Address
First Line	:	420 AZALEA WAY
Second Line	:
City	:	LOS ALTOS
State	:	CA
Zip	:	94022-3859
Country	:	US
Telephone Number	:	650-400-6915
Fax Number	:

Provider Business Practice Location Address
First Line	:	420 AZALEA WAY
Second Line	:
City	:	LOS ALTOS
State	:	CA
Zip	:	94022-3859
Country	:	US
Telephone Number	:	650-400-6915
Fax Number	:

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

Provider Enumeration Date	:	06/03/2021
Last Update Date	:	06/03/2021

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Directions to “ MARLA GOODMAN ” Practice Location

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