MEDICARE: SUSIE GOODRIDGE P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	WPT28989A	CA

General Provider Information

NPI Number	:	1760405658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSIE GOODRIDGE P.T.

Provider Business Mailing Address
First Line	:	11645 GORHAM AVE
Second Line	:	#304
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-4769
Country	:	US
Telephone Number	:	310-996-0085
Fax Number	:	310-996-1064

Provider Business Practice Location Address
First Line	:	11600 WILSHIRE BLVD
Second Line	:	LL14
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-5781
Country	:	US
Telephone Number	:	310-996-0085
Fax Number	:	310-996-1064

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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Directions to “ SUSIE GOODRIDGE P.T.” Practice Location

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