Provider Demographics
NPI:1487142980
Name:GOODRICH, MONICA
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 ALEXANDER AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-1509
Mailing Address - Country:US
Mailing Address - Phone:973-932-9312
Mailing Address - Fax:
Practice Address - Street 1:WINCHESTER GARDENS
Practice Address - Street 2:333 ELMWOOD AVE
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040
Practice Address - Country:US
Practice Address - Phone:973-762-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTL-3055390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program