Provider Demographics
NPI:1386182566
Name:GOEDEKER, LORI (PTA)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:GOEDEKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:
Other - Last Name:SERRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1702 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-3652
Mailing Address - Country:US
Mailing Address - Phone:402-682-4808
Mailing Address - Fax:
Practice Address - Street 1:1702 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3652
Practice Address - Country:US
Practice Address - Phone:402-682-4808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00869225200000X
NE593225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant