Provider Demographics
NPI:1790919629
Name:GOODNOUGH, STEPHEN (PTA)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:GOODNOUGH
Suffix:
Gender:M
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:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WA
Mailing Address - Zip Code:98236-0031
Mailing Address - Country:US
Mailing Address - Phone:360-678-2273
Mailing Address - Fax:360-678-8715
Practice Address - Street 1:311 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239-3427
Practice Address - Country:US
Practice Address - Phone:360-678-2273
Practice Address - Fax:360-678-8715
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60045654225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant