Provider Demographics
NPI:1114478542
Name:GOODLOW, CARRESHA
Entity Type:Individual
Prefix:
First Name:CARRESHA
Middle Name:
Last Name:GOODLOW
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:PO BOX 6561
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-0561
Mailing Address - Country:US
Mailing Address - Phone:731-444-2577
Mailing Address - Fax:
Practice Address - Street 1:W8007 SOUTH US 141/2
Practice Address - Street 2:#334
Practice Address - City:IRON
Practice Address - State:MI
Practice Address - Zip Code:49801-9466
Practice Address - Country:US
Practice Address - Phone:731-444-2577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI27014379601744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management