Provider Demographics
NPI:1730300518
Name:GOODALL, FAY ALLEN (PT)
Entity Type:Individual
Prefix:MR
First Name:FAY
Middle Name:ALLEN
Last Name:GOODALL
Suffix:
Gender:M
Credentials:PT
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 2316
Mailing Address - Street 2:
Mailing Address - City:POST FALL
Mailing Address - State:ID
Mailing Address - Zip Code:83877
Mailing Address - Country:US
Mailing Address - Phone:208-457-8746
Mailing Address - Fax:208-457-8767
Practice Address - Street 1:185 W 4TH AVE
Practice Address - Street 2:STE C
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-4979
Practice Address - Country:US
Practice Address - Phone:208-457-8746
Practice Address - Fax:208-457-8767
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002838225100000X
CAPT 10062225100000X
IDPT-286225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002609200Medicaid
82040818683854A003OtherTRICARE
ID000010019002OtherREGENCE BLUE SHIELD
ID4004OtherSTATE INSURANCE FUND
IDT-5345OtherBLUE CROSS
WA2937OtherWASHINGTON LABOR & INDUST