Provider Demographics
NPI:1275083651
Name:GOFORTH, MICHAEL L (AUD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:GOFORTH
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7215 COMMONS CIR UNIT C
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-2666
Mailing Address - Country:US
Mailing Address - Phone:307-637-7415
Mailing Address - Fax:
Practice Address - Street 1:3400 OLD MILTON PKWY
Practice Address - Street 2:BLDG C, STE 575
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-3707
Practice Address - Country:US
Practice Address - Phone:770-410-0202
Practice Address - Fax:770-410-0955
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYA-1012237600000X
GAAUD004125231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter