Provider Demographics
NPI:1619708286
Name:GOODELL, MARIAH
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:GOODELL
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 1:17816 W JESSIE LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85387-4056
Mailing Address - Country:US
Mailing Address - Phone:720-377-5799
Mailing Address - Fax:
Practice Address - Street 1:16350 N PAT TILLMAN BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85387
Practice Address - Country:US
Practice Address - Phone:480-863-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPTA-014534225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant