Provider Demographics
NPI:1518467075
Name:GOODMAN, KATHRYN ELEN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELEN
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 S PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-3488
Mailing Address - Country:US
Mailing Address - Phone:517-975-2091
Mailing Address - Fax:517-975-2129
Practice Address - Street 1:2727 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3488
Practice Address - Country:US
Practice Address - Phone:517-975-2091
Practice Address - Fax:517-975-2129
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003921225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1134104672Medicaid