Provider Demographics
NPI:1073897682
Name:GODINO, BROOKE NICHOLE (PT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICHOLE
Last Name:GODINO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2525 N GRANDVIEW AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-1600
Mailing Address - Country:US
Mailing Address - Phone:432-550-4700
Mailing Address - Fax:432-550-4715
Practice Address - Street 1:2545 PERRYTON PKWY STE 35
Practice Address - Street 2:
Practice Address - City:PAMPA
Practice Address - State:TX
Practice Address - Zip Code:79065-2820
Practice Address - Country:US
Practice Address - Phone:806-486-1697
Practice Address - Fax:806-412-5573
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1200317225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX259315YKXCMedicare UPIN