Provider Demographics
NPI:1346977394
Name:GOODWIN, PAIGE ALEXIS (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:PAIGE
Middle Name:ALEXIS
Last Name:GOODWIN
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 1:4933 OLD GREENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-6906
Mailing Address - Country:US
Mailing Address - Phone:479-201-6058
Mailing Address - Fax:
Practice Address - Street 1:N15W28300 GOLF RD
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-4800
Practice Address - Country:US
Practice Address - Phone:262-303-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8009-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI8009-26OtherWISCONSIN OCCUPATIONAL THERAPY LICENSE