Provider Demographics
NPI:1164865226
Name:GOODSON, NICOLE CHRISTINE (OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CHRISTINE
Last Name:GOODSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10767 KAY BERRIE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-5944
Mailing Address - Country:US
Mailing Address - Phone:812-499-1762
Mailing Address - Fax:
Practice Address - Street 1:11960 WESTLINE INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3209
Practice Address - Country:US
Practice Address - Phone:866-433-9555
Practice Address - Fax:314-275-7444
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013002585225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist