Provider Demographics
NPI:1326685918
Name:GOEDE, KELLY R (LMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:GOEDE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 N 2ND ST E
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3509
Mailing Address - Country:US
Mailing Address - Phone:307-851-9979
Mailing Address - Fax:
Practice Address - Street 1:107 S BROADWAY
Practice Address - Street 2:STE 203 AND 204
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501
Practice Address - Country:US
Practice Address - Phone:307-851-9979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty