Healthcare Provider Details

I. General information

NPI: 1770220246
Provider Name (Legal Business Name): HAILEY GOFORTH OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date: 05/17/2022
Reactivation Date: 07/01/2022

III. Provider practice location address

3031 BEVERLY BLVD STE B
LOS ANGELES CA
90057-1013
US

IV. Provider business mailing address

3031 BEVERLY BLVD STE B
LOS ANGELES CA
90057-1013
US

V. Phone/Fax

Practice location:
  • Phone: 323-644-9380
  • Fax:
Mailing address:
  • Phone: 323-644-9380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number22985
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: