Provider Demographics
NPI:1982748570
Name:GOODRUM, LESLIE KENDLE
Entity Type:Individual
Prefix:MISS
First Name:LESLIE
Middle Name:KENDLE
Last Name:GOODRUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11601 S MAZE CT
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-2319
Mailing Address - Country:US
Mailing Address - Phone:480-753-6360
Mailing Address - Fax:
Practice Address - Street 1:38201 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:TONOPAH
Practice Address - State:AZ
Practice Address - Zip Code:85354-7301
Practice Address - Country:US
Practice Address - Phone:623-386-5688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0753225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ225XP0200XMedicaid