Provider Demographics
NPI:1184173916
Name:GOODWIN, LESLIE (PTA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6403 COYLE AVE
Mailing Address - Street 2:STE. 350
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0311
Mailing Address - Country:US
Mailing Address - Phone:916-536-9130
Mailing Address - Fax:916-536-9317
Practice Address - Street 1:6403 COYLE AVE
Practice Address - Street 2:STE. 350
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0311
Practice Address - Country:US
Practice Address - Phone:916-536-9130
Practice Address - Fax:916-536-9317
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48252225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant