Healthcare Provider Details

I. General information

NPI: 1568664423
Provider Name (Legal Business Name): JUSTINE A GOODWIN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2636 S MILFORD RD
HIGHLAND MI
48357-4938
US

IV. Provider business mailing address

2636 S MILFORD RD
HIGHLAND MI
48357-4938
US

V. Phone/Fax

Practice location:
  • Phone: 248-684-9610
  • Fax:
Mailing address:
  • Phone: 810-923-3142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502001494
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: