Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 209892 | TX |
NPI | 1013497270 |
---|---|
Provider Name | Dekedria Goodwin |
First Address | Corsicana, TX 75110-4564 |
Second Address | Corsicana, TX 75110-4564 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2018 |
Last Update Date | 17/08/2018 |