Provider Demographics
NPI:1942667936
Name:GODBOUT, SHARON C (DPT)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:C
Last Name:GODBOUT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:M
Other - Last Name:CASEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 CREDIT UNION WAY FL 3
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4633
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:173 ESSEX ST FL 1
Practice Address - Street 2:
Practice Address - City:SWAMPSCOTT
Practice Address - State:MA
Practice Address - Zip Code:01907-1150
Practice Address - Country:US
Practice Address - Phone:781-586-0550
Practice Address - Fax:781-586-0125
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19183225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6079445OtherAETNA
MA110113561AMedicaid