Provider Demographics
NPI:1962916205
Name:GOODMAN, CAROLINE MUELLER (114005 MASSAGE LIC)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:MUELLER
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:114005 MASSAGE LIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12350 NOCH DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-9309
Mailing Address - Country:US
Mailing Address - Phone:907-942-0479
Mailing Address - Fax:
Practice Address - Street 1:326 CENTER AVE STE 100
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-7302
Practice Address - Country:US
Practice Address - Phone:907-486-4042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK114005225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist