MEDICARE: MS. DEBRA LEA GOODAN 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	PTA002161	GA

General Provider Information

NPI Number	:	1639299654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DEBRA LEA GOODAN PTA

Provider Business Mailing Address
First Line	:	20310 SUGARLOAF RESERVE DR
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30097-5217
Country	:	US
Telephone Number	:	770-814-0878
Fax Number	:

Provider Business Practice Location Address
First Line	:	20310 SUGARLOAF RESERVE DR
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30097-5217
Country	:	US
Telephone Number	:	770-814-0878
Fax Number	:

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

Provider Enumeration Date	:	03/31/2007
Last Update Date	:	07/08/2007

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