Provider Demographics
NPI:1205949781
Name:GOODMAN, LESA A (PT)
Entity type:Individual
Prefix:MRS
First Name:LESA
Middle Name:A
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:LESA
Other - Middle Name:A
Other - Last Name:LASSWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:939 HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2910
Mailing Address - Country:US
Mailing Address - Phone:636-240-7000
Mailing Address - Fax:636-240-7513
Practice Address - Street 1:939 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2910
Practice Address - Country:US
Practice Address - Phone:636-240-7000
Practice Address - Fax:636-240-7513
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117046225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist