Provider Demographics
NPI:1124170840
Name:GOODRICH, ROCHELLE MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:MARIE
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:ROCHELLE
Other - Middle Name:MARIE
Other - Last Name:KREDOVSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LACD
Mailing Address - Street 1:1439 N 8TH AVE EAST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-464-8136
Mailing Address - Fax:
Practice Address - Street 1:FOND DU LAC HUMAN SERVICES DIVISION
Practice Address - Street 2:927 TRETTEL LANE
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720
Practice Address - Country:US
Practice Address - Phone:218-879-1227
Practice Address - Fax:218-878-2188
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN221041041C0700X
MN301771101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNNPPOOOtherFDLHSD MEDICARE
MN666815100OtherFDLHSD MEDICAIDE