Provider Demographics
NPI:1417226762
Name:GOODBAR, AUDREY MAVIS (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:MAVIS
Last Name:GOODBAR
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
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 7350
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-7350
Mailing Address - Country:US
Mailing Address - Phone:310-995-0036
Mailing Address - Fax:
Practice Address - Street 1:2352 PARNELL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-2202
Practice Address - Country:US
Practice Address - Phone:310-995-0036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29412225700000X, 173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist