Healthcare Provider Details

I. General information

NPI: 1366073496
Provider Name (Legal Business Name): TAMARA L GOLDRICK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 BROADRIDGE DR
JACKSON MO
63755-3042
US

IV. Provider business mailing address

3422 GLENVIEW DR
CAPE GIRARDEAU MO
63701-3446
US

V. Phone/Fax

Practice location:
  • Phone: 888-365-6271
  • Fax:
Mailing address:
  • Phone: 573-270-9335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2018024000
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: