Provider Demographics
NPI:1730921297
Name:GOODRICH, TRACI (REGISTERED ASSOCIATE)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:REGISTERED ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15315 SE LEE AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-2639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:LIFESTANCE HEALTH
Practice Address - Street 2:880 82ND DRIVE
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027
Practice Address - Country:US
Practice Address - Phone:503-659-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR9311106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist