Provider Demographics
NPI:1376880054
Name:GOODING, KETORUS (M04953)
Entity Type:Individual
Prefix:
First Name:KETORUS
Middle Name:
Last Name:GOODING
Suffix:
Gender:M
Credentials:M04953
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9837 BALE CT
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-6106
Mailing Address - Country:US
Mailing Address - Phone:443-801-8955
Mailing Address - Fax:
Practice Address - Street 1:9837 BALE CT
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-6106
Practice Address - Country:US
Practice Address - Phone:443-801-8955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM04953225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist