Provider Demographics
NPI:1316007453
Name:GOODRICH, FREDERICK GREG (PHD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:GREG
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 W MAIN ST
Mailing Address - Street 2:STE 7
Mailing Address - City:BAYSHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706
Mailing Address - Country:US
Mailing Address - Phone:631-665-3768
Mailing Address - Fax:631-665-3768
Practice Address - Street 1:260 W MAIN ST
Practice Address - Street 2:STE 7
Practice Address - City:BAYSHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-665-3768
Practice Address - Fax:631-665-3768
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY08100103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00918332Medicaid
NY00918332Medicaid
R51408Medicare UPIN