Healthcare Provider Details

I. General information

NPI: 1942644216
Provider Name (Legal Business Name): SHARON L. GOEDKOOP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2458 CHRISTIAN STREET SUITE 214
WILDER VT
05088
US

IV. Provider business mailing address

PO BOX 842
WILDER VT
05088-0842
US

V. Phone/Fax

Practice location:
  • Phone: 802-356-9393
  • Fax:
Mailing address:
  • Phone: 802-356-9393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0001132
License Number StateVT

VIII. Authorized Official

Name: SHARON L. GOEDKOOP
Title or Position: LICENSED SOCIAL WORKER
Credential: LICSW
Phone: 802-356-9393