Provider Demographics
NPI:1861737025
Name:GOODELL, RENAE (PTA, LMP)
Entity type:Individual
Prefix:
First Name:RENAE
Middle Name:
Last Name:GOODELL
Suffix:
Gender:F
Credentials:PTA, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7405 38TH DR SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-7106
Mailing Address - Country:US
Mailing Address - Phone:336-327-8975
Mailing Address - Fax:
Practice Address - Street 1:7405 38TH DR SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-7106
Practice Address - Country:US
Practice Address - Phone:336-327-8975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60046677225200000X
WAMA 60453128225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist