Provider Demographics
NPI:1750865598
Name:GOODFELLOW, JOHN EDWARD (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:GOODFELLOW
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 W SHAW AVE BLDG A
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3334
Mailing Address - Country:US
Mailing Address - Phone:559-228-9100
Mailing Address - Fax:559-432-8055
Practice Address - Street 1:2505 W SHAW AVE BLDG A
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3334
Practice Address - Country:US
Practice Address - Phone:559-228-9100
Practice Address - Fax:559-432-8055
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2598225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2598OtherBOARD OF OCCUPATIONAL THERAPY