Provider Demographics
NPI:1821490764
Name:GOODROAD, MIRANDA ROSE (LMP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ROSE
Last Name:GOODROAD
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8615 S TACOMA WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-4542
Mailing Address - Country:US
Mailing Address - Phone:253-588-3355
Mailing Address - Fax:
Practice Address - Street 1:8615 S TACOMA WAY
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-4542
Practice Address - Country:US
Practice Address - Phone:253-588-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00025034225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist