Basic Information
| Provider Information | |||||||||
| NPI: | 1124170840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODRICH | ||||||||
| FirstName: | ROCHELLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KREDOVSKI | ||||||||
| OtherFirstName: | ROCHELLE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LACD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1439 N 8TH AVE EAST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184648136 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | FOND DU LAC HUMAN SERVICES DIVISION | ||||||||
| Address2: | 927 TRETTEL LANE | ||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791227 | ||||||||
| FaxNumber: | 2188782188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 06/30/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 22104 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 301771 | MN | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | NPPOO | 01 | MN | FDLHSD MEDICARE | OTHER | 666815100 | 01 | MN | FDLHSD MEDICAIDE | OTHER |