Provider Demographics
NPI:1841805058
Name:GOODING, KRISTA L (PT)
Entity Type:Individual
Prefix:MS
First Name:KRISTA
Middle Name:L
Last Name:GOODING
Suffix:
Gender:F
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:PO BOX 1343
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-1343
Mailing Address - Country:US
Mailing Address - Phone:618-452-1986
Mailing Address - Fax:618-452-6814
Practice Address - Street 1:1525 JOHNSON RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3831
Practice Address - Country:US
Practice Address - Phone:618-452-1986
Practice Address - Fax:618-452-6814
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.017546225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist