Healthcare Provider Details

I. General information

NPI: 1275693871
Provider Name (Legal Business Name): MARY GOODRICH MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 LADUE RD. SUITE 336
ST. LOUIS MO
63124-2079
US

IV. Provider business mailing address

10672 COUNTRY VIEW DR
CREVE COEUR MO
63141-7819
US

V. Phone/Fax

Practice location:
  • Phone: 314-754-3259
  • Fax:
Mailing address:
  • Phone: 314-494-1809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005247
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier49848813
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: