Provider Demographics
NPI:1013257484
Name:GOEDKOOP, SHARON L (LICSW, PLLC)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:L
Last Name:GOEDKOOP
Suffix:
Gender:F
Credentials:LICSW, PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 842
Mailing Address - Street 2:
Mailing Address - City:WILDER
Mailing Address - State:VT
Mailing Address - Zip Code:05088-0842
Mailing Address - Country:US
Mailing Address - Phone:802-359-2553
Mailing Address - Fax:
Practice Address - Street 1:2458 CHRISTIAN ST
Practice Address - Street 2:SUITE 214
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-9855
Practice Address - Country:US
Practice Address - Phone:802-359-2553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0890001132104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1021546Medicaid
VT1013257484OtherBLUE CROSS/BLUE SHIELD
NH3086010Medicaid
VT4583988OtherCIGNA