=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356537864
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA A GOODLEIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2007
-----------------------------------------------------
Last Update Date | 09/18/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2625 E SAINT LOUIS AVE
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89104-4200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 170-279-9746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3773 CORPOLO AVE
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89141-3483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-755-6845
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 009951-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------