Provider Demographics
NPI:1710336235
Name:MARINO-GOODRICH, STEFANIE M (LMFT)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:M
Last Name:MARINO-GOODRICH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 HEMPSTEAD ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-6204
Mailing Address - Country:US
Mailing Address - Phone:860-443-2896
Mailing Address - Fax:860-442-5909
Practice Address - Street 1:591 POQUONNOCK RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4571
Practice Address - Country:US
Practice Address - Phone:860-449-8217
Practice Address - Fax:860-449-8323
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CT2041106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor