Provider Demographics
NPI:1760405658
Name:GOODRIDGE, SUSIE (PT)
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:GOODRIDGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11645 GORHAM AVE
Mailing Address - Street 2:#304
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-4769
Mailing Address - Country:US
Mailing Address - Phone:310-996-0085
Mailing Address - Fax:310-996-1064
Practice Address - Street 1:11600 WILSHIRE BLVD
Practice Address - Street 2:LL14
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5781
Practice Address - Country:US
Practice Address - Phone:310-996-0085
Practice Address - Fax:310-996-1064
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAWPT28989A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT28989AMedicare ID - Type Unspecified