Provider Demographics
NPI:1386098523
Name:GOODALE, NIKKI (OTR, CLT)
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:GOODALE
Suffix:
Gender:F
Credentials:OTR, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1849 LAMAR AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-1463
Mailing Address - Country:US
Mailing Address - Phone:903-316-6386
Mailing Address - Fax:
Practice Address - Street 1:2710 E PRICE ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460
Practice Address - Country:US
Practice Address - Phone:903-784-3173
Practice Address - Fax:903-784-7912
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114230225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist