Provider Demographics
NPI:1144905100
Name:GOODGAME, DOREEN
Entity type:Individual
Prefix:
First Name:DOREEN
Middle Name:
Last Name:GOODGAME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10158 STONEHENGE CIR APT 802
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-3546
Mailing Address - Country:US
Mailing Address - Phone:954-816-2974
Mailing Address - Fax:
Practice Address - Street 1:10158 STONEHENGE CIR APT 802
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3546
Practice Address - Country:US
Practice Address - Phone:954-816-2974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11276224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant