Provider Demographics
NPI:1720403108
Name:GOODWILL, DENICE (PTA)
Entity Type:Individual
Prefix:
First Name:DENICE
Middle Name:
Last Name:GOODWILL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 CANTWELL CT
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-9221
Mailing Address - Country:US
Mailing Address - Phone:336-886-6095
Mailing Address - Fax:
Practice Address - Street 1:3504 FLINT ST APT D225
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3298
Practice Address - Country:US
Practice Address - Phone:336-545-4157
Practice Address - Fax:336-545-4587
Is Sole Proprietor?:No
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5270225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant