Basic Information
| Provider Information | |||||||||
| NPI: | 1649380924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 W GLEN OAKS LN STE 110 | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530923392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622446178 | ||||||||
| FaxNumber: | 2622993040 | ||||||||
| Practice Location | |||||||||
| Address1: | W175N11081 STONEWOOD DR STE 212 | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530224771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622446177 | ||||||||
| FaxNumber: | 2622993040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2581-057 | WI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 000084137 | 01 | WI | MEDICARE | OTHER | 39152500 | 05 | WI | MEDICAID |