Provider Demographics
NPI:1629039854
Name:GOODMAN, MARK DAVID (PHD FPPR)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:PHD FPPR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1221
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67504-1221
Mailing Address - Country:US
Mailing Address - Phone:620-663-4802
Mailing Address - Fax:620-663-9867
Practice Address - Street 1:125 W. 2ND AVENUE
Practice Address - Street 2:SUITE E
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67501-5300
Practice Address - Country:US
Practice Address - Phone:620-663-4802
Practice Address - Fax:620-663-9867
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS374103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100237680AMedicaid
KS004369Medicare ID - Type Unspecified
KS100237680AMedicaid