Provider Demographics
NPI:1770220246
Name:GOFORTH, HAILEY (OTR/L)
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 S DOMMER AVE
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3680 E IMPERIAL HWY STE 504
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2659
Practice Address - Country:US
Practice Address - Phone:310-807-7545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2023-10-18
Deactivation Date:2022-05-17
Deactivation Code:
Reactivation Date:2022-07-01
Provider Licenses
StateLicense IDTaxonomies
CA22985225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty