Provider Demographics
NPI:1164753984
Name:GOODRICH, MARY ANNE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
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 1:1103 N B ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811-0326
Mailing Address - Country:US
Mailing Address - Phone:792-201-4041
Mailing Address - Fax:
Practice Address - Street 1:1103 N B ST STE E
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-0326
Practice Address - Country:US
Practice Address - Phone:916-388-9418
Practice Address - Fax:916-388-9273
Is Sole Proprietor?:No
Enumeration Date:2010-01-18
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)