Provider Demographics
NPI:1902886641
Name:GOODMAN, TERESA MARIE (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:MARIE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 28 RD
Mailing Address - Street 2:STE B209
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-6556
Mailing Address - Country:US
Mailing Address - Phone:970-245-3212
Mailing Address - Fax:970-245-3216
Practice Address - Street 1:518 28 RD
Practice Address - Street 2:STE B209
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6556
Practice Address - Country:US
Practice Address - Phone:970-245-3212
Practice Address - Fax:970-245-3216
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1360101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO605638OtherBCBS
CO082236OtherVALUE OPTIONS - CHN
CO91122228Medicaid