Provider Demographics
NPI:1164722252
Name:GOODRICH, KIMBERLY A
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:A
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 S GEMINI RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-5801
Mailing Address - Country:US
Mailing Address - Phone:405-589-9623
Mailing Address - Fax:
Practice Address - Street 1:1209 S GEMINI RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-5801
Practice Address - Country:US
Practice Address - Phone:405-589-9623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-24
Last Update Date:2010-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)