Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 14870 | TX |
Y | 103T00000X | Psychologist | 14870 | TX |
NPI | 1003168311 |
---|---|
Provider Name | Alisa Goodman |
First Address | Tyler, TX 75702-7704 |
Second Address | Tyler, TX 75702-7704 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2012 |
Last Update Date | 10/10/2012 |