Provider Demographics
NPI:1033291620
Name:GODIKSEN, KRISTIN (PT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:GODIKSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 JEROME AVENUEE
Mailing Address - Street 2:SUITE # 305
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3064
Mailing Address - Country:US
Mailing Address - Phone:860-519-1916
Mailing Address - Fax:
Practice Address - Street 1:34 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2463
Practice Address - Country:US
Practice Address - Phone:860-519-1916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002340225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002340OtherPHYSICAL THERAPY LICENSE