Provider Demographics
NPI:1609844513
Name:GOUDEY, SKY R (PT)
Entity Type:Individual
Prefix:
First Name:SKY
Middle Name:R
Last Name:GOUDEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3760 CONVOY ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3743
Mailing Address - Country:US
Mailing Address - Phone:888-208-8526
Mailing Address - Fax:858-751-0901
Practice Address - Street 1:72840 HIGHWAY 111 STE A-150
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3324
Practice Address - Country:US
Practice Address - Phone:858-614-6332
Practice Address - Fax:858-614-6324
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2018-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002582225100000X
CAPT292957225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA18397OtherL&I
WA7270200Medicaid
WAG000800109Medicare PIN