Provider Demographics
NPI:1831394907
Name:GOODRICH, THOMAS LEE JR (PT)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:LEE
Last Name:GOODRICH
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-1454
Mailing Address - Country:US
Mailing Address - Phone:330-702-0110
Mailing Address - Fax:330-702-0510
Practice Address - Street 1:4329 MAHONING AVE NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-1974
Practice Address - Country:US
Practice Address - Phone:330-702-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 008879225100000X
PAPT 012992L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA230185YFTYMedicare PIN