Provider Demographics
NPI:1669157988
Name:GOODALE, HOLLY RAE (CSA, LSA, CSFA)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:RAE
Last Name:GOODALE
Suffix:
Gender:F
Credentials:CSA, LSA, CSFA
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:RAE
Other - Last Name:MORDOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2801 E MAIN ST APT 716
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-7917
Mailing Address - Country:US
Mailing Address - Phone:301-956-5489
Mailing Address - Fax:
Practice Address - Street 1:5801 BREMO RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1907
Practice Address - Country:US
Practice Address - Phone:804-285-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136000808246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant