Provider Demographics
NPI:1659659266
Name:GOODRICH, ALLISON L
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:L
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 1:326 HARBAUGH DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-3663
Mailing Address - Country:US
Mailing Address - Phone:619-540-1124
Mailing Address - Fax:
Practice Address - Street 1:326 HARBAUGH DR UNIT B
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-3663
Practice Address - Country:US
Practice Address - Phone:619-540-1124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-31
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY262006106H00000X
TN1489106H00000X
CA97915106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist