Provider Demographics
NPI:1457427098
Name:GOODMAN, SUSAN E (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:E
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 GROVE ST
Mailing Address - Street 2:2C/2D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-5310
Mailing Address - Country:US
Mailing Address - Phone:212-541-7600
Mailing Address - Fax:917-690-8321
Practice Address - Street 1:42 GROVE ST
Practice Address - Street 2:2C/2D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-5310
Practice Address - Country:US
Practice Address - Phone:212-541-7600
Practice Address - Fax:917-690-8321
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005613-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02029541Medicaid
NY02029541Medicaid