Provider Demographics
NPI:1578924429
Name:LESLIE-GOODEN, CARLA
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:LESLIE-GOODEN
Suffix:
Gender:F
Credentials:
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 292
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-0292
Mailing Address - Country:US
Mailing Address - Phone:678-870-4467
Mailing Address - Fax:770-626-3421
Practice Address - Street 1:170 BASTILLE WAY STE A
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7652
Practice Address - Country:US
Practice Address - Phone:678-870-4467
Practice Address - Fax:770-626-3421
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility