MEDICARE: PATRICIA GARDNER-GOODOF LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1022482	MA

General Provider Information

NPI Number	:	1558381517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA GARDNER-GOODOF LICSW

Provider Business Mailing Address
First Line	:	95 CLIFTON AVE
Second Line	:
City	:	MARBLEHEAD
State	:	MA
Zip	:	01945-1717
Country	:	US
Telephone Number	:	781-639-1193
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 PLEASANT LN
Second Line	:
City	:	MARBLEHEAD
State	:	MA
Zip	:	01945-2341
Country	:	US
Telephone Number	:	781-631-2666
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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