Provider Demographics
NPI:1932532041
Name:GOODWIN, LAURIE D (PTA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:D
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 1:310 N DIXIE HWY
Mailing Address - Street 2:#105
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-6814
Mailing Address - Country:US
Mailing Address - Phone:561-827-6982
Mailing Address - Fax:
Practice Address - Street 1:310 N DIXIE HWY
Practice Address - Street 2:#105
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-6814
Practice Address - Country:US
Practice Address - Phone:561-827-6982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21614225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant