Provider Demographics
NPI:1215285788
Name:GOODMAN, LAURA K (ATC)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:K
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:K
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:12081 MASON DR
Mailing Address - Street 2:
Mailing Address - City:QUANTICO
Mailing Address - State:VA
Mailing Address - Zip Code:22134-2003
Mailing Address - Country:US
Mailing Address - Phone:610-764-0027
Mailing Address - Fax:
Practice Address - Street 1:12081 MASON DR
Practice Address - Street 2:
Practice Address - City:QUANTICO
Practice Address - State:VA
Practice Address - Zip Code:22134
Practice Address - Country:US
Practice Address - Phone:610-764-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA20000078172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer