Provider Demographics
NPI:1164757613
Name:GOODRICH, REBECCA MARIE (LMP, NCTMB)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:MARIE
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:LMP, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3162
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-1907
Mailing Address - Country:US
Mailing Address - Phone:208-310-9375
Mailing Address - Fax:
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:GRITMAN MEDICAL CENTER
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3056
Practice Address - Country:US
Practice Address - Phone:208-883-6361
Practice Address - Fax:208-883-6452
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60098139225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist