Provider Demographics
NPI:1780730523
Name:GOODRICH, GREGORY B (LPC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:B
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9225 SANDY LN
Mailing Address - Street 2:
Mailing Address - City:CONIFER
Mailing Address - State:CO
Mailing Address - Zip Code:80433-9501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5924 US HIGHWAY 285
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:CO
Practice Address - Zip Code:80465-9101
Practice Address - Country:US
Practice Address - Phone:303-697-0235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120704103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN120704OtherTRIBAL LICENSE