Provider Demographics
NPI:1154418663
Name:GOODMAN, ROBERT MACY (MA, MS)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MACY
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 LOST NATION RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-2428
Mailing Address - Country:US
Mailing Address - Phone:802-879-0439
Mailing Address - Fax:802-860-3613
Practice Address - Street 1:35 TIMBER LN
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-5201
Practice Address - Country:US
Practice Address - Phone:802-651-7562
Practice Address - Fax:802-860-3613
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0000429103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1002609Medicaid