Provider Demographics
NPI:1467538553
Name:GOODACRE, MARY E (MA, CCCA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:GOODACRE
Suffix:
Gender:F
Credentials:MA, CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 RALPH PL STE 308
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4419
Mailing Address - Country:US
Mailing Address - Phone:718-981-6020
Mailing Address - Fax:718-876-8370
Practice Address - Street 1:11 RALPH PL STE 308
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-4419
Practice Address - Country:US
Practice Address - Phone:718-981-6020
Practice Address - Fax:718-876-8370
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY603231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02148901Medicaid
NYM90921Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER