Provider Demographics
NPI:1538481700
Name:GOODWILL, LAURIE ELAINE (MA CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:ELAINE
Last Name:GOODWILL
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4291 HARLEM RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-4428
Mailing Address - Country:US
Mailing Address - Phone:716-839-1088
Mailing Address - Fax:
Practice Address - Street 1:97 HAMBURG ST
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-2139
Practice Address - Country:US
Practice Address - Phone:716-652-6464
Practice Address - Fax:716-652-6499
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005128-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400012391Medicare PIN