Provider Demographics
NPI:1306137005
Name:GOODMAN, KEVIN MICHAL ANDREW
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAL ANDREW
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4558
Mailing Address - Country:US
Mailing Address - Phone:805-781-4973
Mailing Address - Fax:
Practice Address - Street 1:1523 LONGBRANCH AVE
Practice Address - Street 2:
Practice Address - City:GROVER BEACH
Practice Address - State:CA
Practice Address - Zip Code:93433-2508
Practice Address - Country:US
Practice Address - Phone:805-473-7006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104925106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist