Healthcare Provider Details

I. General information

NPI: 1316007453
Provider Name (Legal Business Name): FREDERICK GREG GOODRICH PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 W MAIN ST STE 7
BAYSHORE NY
11706
US

IV. Provider business mailing address

260 W MAIN ST STE 7
BAYSHORE NY
11706
US

V. Phone/Fax

Practice location:
  • Phone: 631-665-3768
  • Fax: 631-665-3768
Mailing address:
  • Phone: 631-665-3768
  • Fax: 631-665-3768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number08100
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: