Healthcare Provider Details

I. General information

NPI: 1669157988
Provider Name (Legal Business Name): HOLLY RAE GOODALE CSA, LSA, CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HOLLY RAE MORDOFF

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 BREMO RD
RICHMOND VA
23226-1907
US

IV. Provider business mailing address

2801 E MAIN ST APT 716
RICHMOND VA
23223-7917
US

V. Phone/Fax

Practice location:
  • Phone: 804-285-2011
  • Fax:
Mailing address:
  • Phone: 301-956-5489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number0136000808
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: