MEDICARE: GERIATRIC AND FAMILY MENTAL HEALTH SERVICES, LLC

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	103T00000X	Psychologist	3196	AZ

General Provider Information

NPI Number	:	1679566624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GERIATRIC AND FAMILY MENTAL HEALTH SERVICES, LLC

Provider Business Mailing Address
First Line	:	11110 N TATUM BLVD
Second Line	:	SUITE 103
City	:	PHOENIX
State	:	AZ
Zip	:	85028-1607
Country	:	US
Telephone Number	:	602-432-0800
Fax Number	:	602-443-0401

Provider Business Practice Location Address
First Line	:	11110 N TATUM BLVD
Second Line	:	103
City	:	PHOENIX
State	:	AZ
Zip	:	85028-1607
Country	:	US
Telephone Number	:	602-432-0800
Fax Number	:	602-443-0401

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GARY NEAL GOODMAN
Credential	:	PH.D.
Telephone Number	:	602-432-0800

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	01/08/2015

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