Provider Demographics
NPI:1659558039
Name:GOODRICH, ALISON JANE (OTR)
Entity Type:Individual
Prefix:
First Name:ALISON
Middle Name:JANE
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:ALISON
Other - Middle Name:JANE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR
Mailing Address - Street 1:708 S COOPER ST
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-2941
Mailing Address - Country:US
Mailing Address - Phone:386-503-2006
Mailing Address - Fax:386-868-2477
Practice Address - Street 1:708 S COOPER ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-2941
Practice Address - Country:US
Practice Address - Phone:386-503-2006
Practice Address - Fax:386-868-2477
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13063225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL892785500Medicaid