Provider Demographics
NPI:1164615464
Name:GOODRICH, TANYA (MA)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1047 S WELLS ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7997
Mailing Address - Country:US
Mailing Address - Phone:208-863-0045
Mailing Address - Fax:
Practice Address - Street 1:1047 S WELLS ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7997
Practice Address - Country:US
Practice Address - Phone:208-863-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT-7452101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor