Provider Demographics
NPI:1427674597
Name:GOODMAN, ANNELIESE MARIAH
Entity type:Individual
Prefix:MRS
First Name:ANNELIESE
Middle Name:MARIAH
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ANNELIESE
Other - Middle Name:MARIAH
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1115 REGENCY WAY APT C
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-7181
Mailing Address - Country:US
Mailing Address - Phone:803-335-9085
Mailing Address - Fax:
Practice Address - Street 1:363 W LINCOLN TRAIL BLVD
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-3302
Practice Address - Country:US
Practice Address - Phone:270-352-1133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYRBT-20-125102106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician