Provider Demographics
NPI:1578825915
Name:GOULT, CHRISTOPHER ALLEN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ALLEN
Last Name:GOULT
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-362-8684
Practice Address - Street 1:2295 TOWNE LAKE PKWY
Practice Address - Street 2:STE 148
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5520
Practice Address - Country:US
Practice Address - Phone:770-926-2744
Practice Address - Fax:770-926-2794
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010868A225100000X
GAPT011818225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201110310Medicaid
IN555850005Medicare PIN