Provider Demographics
NPI:1922452275
Name:GOODRICH, BRIAN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 DOUBLE BEACH RD
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-4909
Mailing Address - Country:US
Mailing Address - Phone:203-315-7692
Mailing Address - Fax:203-315-7583
Practice Address - Street 1:100 DOUBLE BEACH RD
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-4909
Practice Address - Country:US
Practice Address - Phone:203-315-7692
Practice Address - Fax:203-315-7583
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0036881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical