Provider Demographics
NPI:1558381517
Name:GARDNER-GOODOF, PATRICIA (LICSW)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:GARDNER-GOODOF
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-1717
Mailing Address - Country:US
Mailing Address - Phone:781-639-1193
Mailing Address - Fax:
Practice Address - Street 1:1 PLEASANT LN
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-2341
Practice Address - Country:US
Practice Address - Phone:781-631-2666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10224821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical