Provider Demographics
NPI:1528312352
Name:GOFORTH, LAURA CARYN (LPTA)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:CARYN
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 RUTLEDGE LN
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35503-6309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1653 TEMPLE AVE N
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:AL
Practice Address - Zip Code:35555-1314
Practice Address - Country:US
Practice Address - Phone:205-932-5966
Practice Address - Fax:205-932-1354
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6167225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant