Provider Demographics
NPI:1376728121
Name:GOODALL, LESLIE JONES (OTRL)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:JONES
Last Name:GOODALL
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 COLLINS RUN LANE
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:VA
Mailing Address - Zip Code:24465
Mailing Address - Country:US
Mailing Address - Phone:540-468-2704
Mailing Address - Fax:
Practice Address - Street 1:926 FIFTH AVENUE
Practice Address - Street 2:POCAHONTAS COUNTY SCHOOLS
Practice Address - City:MARLINTON
Practice Address - State:WV
Practice Address - Zip Code:24954
Practice Address - Country:US
Practice Address - Phone:304-799-4505
Practice Address - Fax:304-799-4499
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV375225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist