Provider Demographics
NPI:1417474008
Name:GOODRICH, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
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 1:2790 N ACADEMY BLVD STE 227
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5338
Mailing Address - Country:US
Mailing Address - Phone:719-425-7771
Mailing Address - Fax:
Practice Address - Street 1:2790 N ACADEMY BLVD STE 227
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5338
Practice Address - Country:US
Practice Address - Phone:719-425-7771
Practice Address - Fax:719-425-7771
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0000547235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist