1104939081 NPI number — MS. BARBARA ANN GOODRIDGE LCSW #5783

Table of content: MS. BARBARA ANN GOODRIDGE LCSW #5783 (NPI 1104939081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104939081 NPI number — MS. BARBARA ANN GOODRIDGE LCSW #5783

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODRIDGE
Provider First Name:
BARBARA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW #5783
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104939081
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8510 KENNEDY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEBASTOPOL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95472-5330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-823-7205
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1209 COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95404-3907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-479-8814
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCS 5783 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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