Provider Demographics
NPI:1962524165
Name:GOODMAN, ELISE SUE (MA CCC)
Entity type:Individual
Prefix:MS
First Name:ELISE
Middle Name:SUE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MA CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 JYRA LN
Mailing Address - Street 2:
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-2738
Mailing Address - Country:US
Mailing Address - Phone:508-238-6870
Mailing Address - Fax:
Practice Address - Street 1:977 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-7406
Practice Address - Country:US
Practice Address - Phone:781-891-0452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3171235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist