Provider Demographics
NPI:1679628598
Name:GOODRICH, LAUREL B (PHD)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:B
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 W CLINCH AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-2524
Mailing Address - Country:US
Mailing Address - Phone:865-212-5299
Mailing Address - Fax:865-525-4026
Practice Address - Street 1:1640 W CLINCH AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2524
Practice Address - Country:US
Practice Address - Phone:865-212-5299
Practice Address - Fax:865-525-4026
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP001313103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3688924Medicaid
TN3688924Medicare ID - Type Unspecified