Provider Demographics
NPI:1699479261
Name:GOODE, MICHAEL THOMAS (OTR/L)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:GOODE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 MABURY ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4461
Mailing Address - Country:US
Mailing Address - Phone:714-905-4066
Mailing Address - Fax:
Practice Address - Street 1:1400 CIRCLE CITY DR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1642
Practice Address - Country:US
Practice Address - Phone:951-735-0252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24742225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist