Provider Demographics
NPI:1811239809
Name:GOODALE, SHEREE (COTA/L)
Entity Type:Individual
Prefix:
First Name:SHEREE
Middle Name:
Last Name:GOODALE
Suffix:
Gender:F
Credentials:COTA/L
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 106
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:VA
Mailing Address - Zip Code:24538-0106
Mailing Address - Country:US
Mailing Address - Phone:434-993-3963
Mailing Address - Fax:434-993-3556
Practice Address - Street 1:1475 LYLE THOMAS RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:VA
Practice Address - Zip Code:24538-3261
Practice Address - Country:US
Practice Address - Phone:434-993-3963
Practice Address - Fax:434-993-3556
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000424224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant