Provider Demographics
NPI:1447317508
Name:GOODRICH, KALYRA ANANDA S
Entity type:Individual
Prefix:
First Name:KALYRA
Middle Name:ANANDA S
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:D
Other - Last Name:HECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:40 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:MANITOU SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80829-1726
Mailing Address - Country:US
Mailing Address - Phone:805-453-7743
Mailing Address - Fax:
Practice Address - Street 1:3480 RAVENCREEK LN
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32766-7043
Practice Address - Country:US
Practice Address - Phone:407-810-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11677225X00000X
COOT.0004466225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890148100Medicaid
FL812089700Medicaid