Provider Demographics
NPI:1356730048
Name:GOODMAN, GRETCHEN SHAY (AT, ATC)
Entity type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:SHAY
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5646 VIA NUEVO DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9404
Mailing Address - Country:US
Mailing Address - Phone:616-334-5812
Mailing Address - Fax:
Practice Address - Street 1:350 LAFAYETTE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4656
Practice Address - Country:US
Practice Address - Phone:616-456-8515
Practice Address - Fax:616-456-8208
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-18
Last Update Date:2015-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010007702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer