Provider Demographics
NPI:1508217233
Name:GOFORTH, MERIDITH JOY
Entity Type:Individual
Prefix:
First Name:MERIDITH
Middle Name:JOY
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MERIDITH
Other - Middle Name:
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2650 N TENAYA WAY STE 180
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-1110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2650 N TENAYA WAY STE 180
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1110
Practice Address - Country:US
Practice Address - Phone:702-240-2952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist