Provider Demographics
NPI:1043558414
Name:GOODRICH, KRISTOPHER MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTOPHER
Middle Name:MICHAEL
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 BROADWAY BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3425
Mailing Address - Country:US
Mailing Address - Phone:315-727-2968
Mailing Address - Fax:
Practice Address - Street 1:218 BROADWAY BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3425
Practice Address - Country:US
Practice Address - Phone:315-727-2968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-19
Last Update Date:2013-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0138741101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health