Provider Demographics
NPI:1093217663
Name:GOFORTH, LINDSEY MELISSA
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:MELISSA
Last Name:GOFORTH
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 1:1446 SLEEPY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-4805
Mailing Address - Country:US
Mailing Address - Phone:936-366-6342
Mailing Address - Fax:
Practice Address - Street 1:1806 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-1226
Practice Address - Country:US
Practice Address - Phone:936-630-4292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109340225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics