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General NPI Number Information
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NPI Number | 1194962878
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Entity Type | Individual
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Provider Name | LORI GOODSON
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Gender | Female
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Dates
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Enumeration Date | 01/16/2009
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Last Update Date | 01/16/2009
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Provider Practice Location Address
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Address Line | 4407 AMARILLO ST
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City | BLYTHEVILLE
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State | AR
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Zip | 72315-5702
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Country | US
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Telephone | 870-532-2229
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 333
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City | LAKE CITY
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State | AR
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Zip | 72437-0333
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA 1700
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License Number State | AR
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