Provider Demographics
NPI:1942847769
Name:GOODWIN, KETASHA
Entity Type:Individual
Prefix:
First Name:KETASHA
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24277-2539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:377 CLONCE ST
Practice Address - Street 2:
Practice Address - City:WEBER CITY
Practice Address - State:VA
Practice Address - Zip Code:24290-7269
Practice Address - Country:US
Practice Address - Phone:276-477-5640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-01
Last Update Date:2019-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant