Provider Demographics
NPI:1780172742
Name:GOODREAU, MONICA JEAN (OT, CHT)
Entity type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:JEAN
Last Name:GOODREAU
Suffix:
Gender:F
Credentials:OT, CHT
Other - Prefix:MISS
Other - First Name:MONICA
Other - Middle Name:JEAN
Other - Last Name:MASTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:1721 S STEPHENSON AVE
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3637
Mailing Address - Country:US
Mailing Address - Phone:906-776-5548
Mailing Address - Fax:906-776-5478
Practice Address - Street 1:1721 S STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3637
Practice Address - Country:US
Practice Address - Phone:906-776-5548
Practice Address - Fax:906-776-5478
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004379225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34-26OtherDEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES OT