Provider Demographics
NPI:1871009563
Name:GOFORTH, OLIVIA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ANN
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 RENEE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-5580
Mailing Address - Country:US
Mailing Address - Phone:203-726-6811
Mailing Address - Fax:
Practice Address - Street 1:49 RENEE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5580
Practice Address - Country:US
Practice Address - Phone:203-726-6811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT106361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008089787Medicaid