Provider Demographics
NPI:1083130066
Name:GOODWIN, LORA
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3518 6TH AVE STE 200A
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-5419
Mailing Address - Country:US
Mailing Address - Phone:253-473-7830
Mailing Address - Fax:253-267-1607
Practice Address - Street 1:3518 6TH AVE STE 200A
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-5419
Practice Address - Country:US
Practice Address - Phone:253-238-1253
Practice Address - Fax:253-267-1607
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60203436225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1134384555OtherSERENITY SPA AND NATURAL HEALTH