Provider Demographics
NPI:1407840648
Name:GOODMAN, WILLIAM ALFRED (PSYD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ALFRED
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 BENMONT AVE
Mailing Address - Street 2:SUITE 25
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-1873
Mailing Address - Country:US
Mailing Address - Phone:802-447-7577
Mailing Address - Fax:802-447-2676
Practice Address - Street 1:160 BENMONT AVE
Practice Address - Street 2:SUITE 25
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-1873
Practice Address - Country:US
Practice Address - Phone:802-447-7577
Practice Address - Fax:802-447-2676
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0000722103T00000X
MA4767103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0522325Medicaid
VT0VN1788Medicaid
MAW04525Medicare PIN
MA0522325Medicaid
NYRB3062Medicare PIN