Provider Demographics
NPI:1093470676
Name:GOODRICH, AMY JUSTINE (RD, IBCLC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JUSTINE
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:RD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57557 COUNTY ROAD 117
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-1300
Mailing Address - Country:US
Mailing Address - Phone:248-953-3277
Mailing Address - Fax:
Practice Address - Street 1:57557 COUNTY ROAD 117
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-1300
Practice Address - Country:US
Practice Address - Phone:248-953-3277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86112260133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered