Provider Demographics
NPI:1003028994
Name:GOODRICH, CRYSTAL ANN (OT)
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:ANN
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SCHOOL STREET
Mailing Address - Street 2:UNIT 204
Mailing Address - City:BERWICK
Mailing Address - State:ME
Mailing Address - Zip Code:03901
Mailing Address - Country:US
Mailing Address - Phone:207-616-8241
Mailing Address - Fax:
Practice Address - Street 1:469 MAIN STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:SPRINGVALE
Practice Address - State:ME
Practice Address - Zip Code:04083
Practice Address - Country:US
Practice Address - Phone:207-324-2888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1010225X00000X
ME1010225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME11364530OtherCAQH
ME061453OtherANTEM ID #