| Doctor Name: | WALLACE GOODMAN |
| NPI Number: | 1427488055 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 2011024580 |
| Business Practice Address: | 501 Highway J N Hayti, MO - 63851 |
| Business Phone Number: | 5733592600 |
| Business Fax Number: | |
| Mailing Address: | 2009 Southwind Cv, DYERSBURG |
| State: | TN |
| Postal Code: | 380248875 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 11/18/2013 |
| NPI Last Update Date: | 11/18/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 2011024580 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MO |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |