Basic Information
| Provider Information | |||||||||
| NPI: | 1760624308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.W. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3201 S TAMARAC DR | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802314360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202484594 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3201 S TAMARAC DR | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802314360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035975000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2009 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | CSW.09923353 | CO | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | CSW.09923353 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 16770587 | 05 | CO | MEDICAID |