Provider Demographics
NPI:1871042853
Name:GODBOLE, AMRUTA
Entity Type:Individual
Prefix:
First Name:AMRUTA
Middle Name:
Last Name:GODBOLE
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 1:2741 N SALISBURY ST
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2741 N SALISBURY ST
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1431
Practice Address - Country:US
Practice Address - Phone:765-464-5135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-01
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010300A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist