Basic Information
Provider Information | |||||||||
NPI: | 1942325659 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOODREAU | ||||||||
FirstName: | DEBRA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DECHELLIS | ||||||||
OtherFirstName: | DEBRA | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PTA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 599 CENTER ST | ||||||||
Address2: |   | ||||||||
City: | LUDLOW | ||||||||
State: | MA | ||||||||
PostalCode: | 010561460 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135836237 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 464 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | AGAWAM | ||||||||
State: | MA | ||||||||
PostalCode: | 010011826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137868000 | ||||||||
FaxNumber: | 4138210733 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 359 | MA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
No ID Information.