Provider Demographics
NPI:1902110786
Name:GOODMAN, MARY CARTER (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CARTER
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1649 RIVER RD W
Mailing Address - Street 2:
Mailing Address - City:CROZIER
Mailing Address - State:VA
Mailing Address - Zip Code:23039-2511
Mailing Address - Country:US
Mailing Address - Phone:804-337-6337
Mailing Address - Fax:
Practice Address - Street 1:4102 E PARHAM RD
Practice Address - Street 2:SUITE A
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-2743
Practice Address - Country:US
Practice Address - Phone:804-672-8588
Practice Address - Fax:804-672-8587
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003985235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist