Provider Demographics
NPI:1427695360
Name:GOODMAN, MONIQUE TAMARA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:TAMARA
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14082 BLUE RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:VA
Mailing Address - Zip Code:23487-6028
Mailing Address - Country:US
Mailing Address - Phone:757-217-6559
Mailing Address - Fax:
Practice Address - Street 1:31023 CAMP PKWY
Practice Address - Street 2:
Practice Address - City:COURTLAND
Practice Address - State:VA
Practice Address - Zip Code:23837-2012
Practice Address - Country:US
Practice Address - Phone:757-562-3007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008190235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist