Provider Demographics
NPI:1285659557
Name:GOODRICH, ELAINE R (LCSW)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:R
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:LCSW
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 824
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:ME
Mailing Address - Zip Code:04084-0824
Mailing Address - Country:US
Mailing Address - Phone:207-642-2098
Mailing Address - Fax:207-642-8976
Practice Address - Street 1:22A OSSIPEE TRAIL WEST
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:ME
Practice Address - Zip Code:04084
Practice Address - Country:US
Practice Address - Phone:207-642-2098
Practice Address - Fax:207-642-8976
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC11401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME003850OtherANTHEM PIN
ME1036508OtherCIGNA PIN
ME004846OtherTRICARE AND HARVARD PILGR
ME5298100OtherAETNA BEHAVIORAL HEALTH
ME149250 (MHS)OtherVALUE OPTIONS PIN
ME5298100OtherAETNA BEHAVIORAL HEALTH