| Doctor Name: | MRS. STACEY P GOODMAN |
| NPI Number: | 1568639490 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | COTA |
| License Number: | 32000767A |
| Business Practice Address: | 926 E Wayne St South Bend, IN - 466173000 |
| Business Phone Number: | 5742338812 |
| Business Fax Number: | 5742338873 |
| Mailing Address: | 10379 Edison Rd, OSCEOLA |
| State: | IN |
| Postal Code: | 465619355 |
| Phone Number: | 5746740575 |
| Fax Number: | 5746740575 |
| NPI Enumeration Date: | 05/09/2008 |
| NPI Last Update Date: | 05/09/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | 32000767A |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IN |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |