Provider Demographics
NPI:1366073496
Name:GOLDRICK, TAMARA L (LCSW)
Entity type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:L
Last Name:GOLDRICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3422 GLENVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-3446
Mailing Address - Country:US
Mailing Address - Phone:573-270-9335
Mailing Address - Fax:
Practice Address - Street 1:710 BROADRIDGE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-3042
Practice Address - Country:US
Practice Address - Phone:888-365-6271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180240001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018024000OtherLICENSE