Provider Demographics
NPI:1982716346
Name:GOODRICH-TAHHAN, DONNA (LCSW)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:GOODRICH-TAHHAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2959 SEAFORD CT
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-4603
Mailing Address - Country:US
Mailing Address - Phone:516-785-7668
Mailing Address - Fax:
Practice Address - Street 1:2959 SEAFORD CT
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-4603
Practice Address - Country:US
Practice Address - Phone:516-785-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR053959-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN0L062Medicare ID - Type Unspecified