Provider Demographics
NPI:1285346635
Name:GOODMAN, SHANNON KIVA
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KIVA
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:KIVA
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6615 ANTHONY AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92845-2207
Mailing Address - Country:US
Mailing Address - Phone:502-649-2110
Mailing Address - Fax:
Practice Address - Street 1:6615 ANTHONY AVE
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92845-2207
Practice Address - Country:US
Practice Address - Phone:502-649-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical