Healthcare Provider Details

I. General information

NPI: 1093916488
Provider Name (Legal Business Name): CHRISTINE ANN GOOD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 SPRUCE
BROOKINGS OR
97415
US

IV. Provider business mailing address

513 HASSETT ST
BROOKINGS OR
97415-8205
US

V. Phone/Fax

Practice location:
  • Phone: 541-469-1062
  • Fax:
Mailing address:
  • Phone: 541-469-5907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8304
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: