Healthcare Provider Details

I. General information

NPI: 1790606978
Provider Name (Legal Business Name): ANN ELIZABETH GOODGAME PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11726 SAN VICENTE BLVD
LOS ANGELES CA
90049-5044
US

IV. Provider business mailing address

1228 HILLGROVE PL
BEVERLY HILLS CA
90210-2713
US

V. Phone/Fax

Practice location:
  • Phone: 424-724-0944
  • Fax:
Mailing address:
  • Phone: 310-927-5853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT24576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: