Provider Demographics
NPI:1003421710
Name:GOODWIN, GRACELYN J (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:GRACELYN
Middle Name:J
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MRS
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:GOODWIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA/L
Mailing Address - Street 1:7820 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:SNEADS
Mailing Address - State:FL
Mailing Address - Zip Code:32460-2232
Mailing Address - Country:US
Mailing Address - Phone:850-557-8686
Mailing Address - Fax:
Practice Address - Street 1:2711 CAPITAL MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4497
Practice Address - Country:US
Practice Address - Phone:850-210-1172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA17498224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant