Provider Demographics
NPI:1134633241
Name:GOODRICH, TONIA MECHELLE (M S)
Entity type:Individual
Prefix:
First Name:TONIA
Middle Name:MECHELLE
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:M S
Other - Prefix:
Other - First Name:TONIA
Other - Middle Name:MECHELLE
Other - Last Name:GOODRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MARTIN AND WILLIAMS
Mailing Address - Street 1:1316 JARED RAY DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-6773
Mailing Address - Country:US
Mailing Address - Phone:931-220-2213
Mailing Address - Fax:
Practice Address - Street 1:1316 JARED RAY DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-6773
Practice Address - Country:US
Practice Address - Phone:931-220-2213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007442101YP2500X
KY165645101YP2500X
TNLPC000000408101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional