Provider Demographics
NPI:1194029512
Name:GOODCHILD, THERESE GEORGETTE (MS, CCC-SLP, MED)
Entity Type:Individual
Prefix:MRS
First Name:THERESE
Middle Name:GEORGETTE
Last Name:GOODCHILD
Suffix:
Gender:F
Credentials:MS, CCC-SLP, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 BRANTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-1705
Mailing Address - Country:US
Mailing Address - Phone:413-695-6670
Mailing Address - Fax:
Practice Address - Street 1:37 BRANTWOOD RD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01602-1705
Practice Address - Country:US
Practice Address - Phone:413-695-6670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0003655235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0304336Medicaid
MA0003655OtherLICENSE #