MEDICARE: LUETISSER ELNORA 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	106S00000X	Behavior Technician		NC

General Provider Information

NPI Number	:	1639001977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUETISSER ELNORA GOODMAN

Provider Business Mailing Address
First Line	:	1000 PARKVIEW DR APT E3
Second Line	:
City	:	LUMBERTON
State	:	NC
Zip	:	28358-7957
Country	:	US
Telephone Number	:	910-444-7908
Fax Number	:	910-444-7908

Provider Business Practice Location Address
First Line	:	1000 PARKVIEW DR APT E3
Second Line	:
City	:	LUMBERTON
State	:	NC
Zip	:	28358-7957
Country	:	US
Telephone Number	:	910-444-7908
Fax Number	:	910-444-7908

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

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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