MEDICARE: MICHELLE GOODRICH PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	6774A	AZ

General Provider Information

NPI Number	:	1376989103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE GOODRICH PTA

Provider Business Mailing Address
First Line	:	15430 N 25TH ST
Second Line	:	APT. 102
City	:	PHOENIX
State	:	AZ
Zip	:	85032-8040
Country	:	US
Telephone Number	:	480-322-9206
Fax Number	:

Provider Business Practice Location Address
First Line	:	15430 N 25TH ST
Second Line	:	APT. 102
City	:	PHOENIX
State	:	AZ
Zip	:	85032-8040
Country	:	US
Telephone Number	:	480-322-9206
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2013
Last Update Date	:	05/20/2013

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Directions to “ MICHELLE GOODRICH PTA” Practice Location

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