Provider Demographics
NPI:1306906136
Name:GOODMAN, JANICE HANSEN (PHD, APRN, BC)
Entity type:Individual
Prefix:DR
First Name:JANICE
Middle Name:HANSEN
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:PHD, APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 MYSTIC VALLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-2936
Mailing Address - Country:US
Mailing Address - Phone:781-775-4963
Mailing Address - Fax:
Practice Address - Street 1:599 NORTH AVENUE
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01801
Practice Address - Country:US
Practice Address - Phone:781-775-4963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA163553364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult