Provider Demographics
NPI:1871705277
Name:GOODRICH, ALICE D (MSPT)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:D
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:D
Other - Last Name:BAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:27 CLEMENTS RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:VT
Mailing Address - Zip Code:05468-3317
Mailing Address - Country:US
Mailing Address - Phone:941-928-7536
Mailing Address - Fax:
Practice Address - Street 1:21 CARMICHAEL ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-3186
Practice Address - Country:US
Practice Address - Phone:941-928-7536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0003688225100000X
FLFL200062081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1017791Medicaid
384501Medicare PIN