Provider Demographics
NPI:1962044990
Name:GOODERMONT, PATRICE
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:
Last Name:GOODERMONT
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 1:475 22ND AVE RM 101
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-4400
Mailing Address - Country:US
Mailing Address - Phone:808-305-9750
Mailing Address - Fax:808-733-9154
Practice Address - Street 1:475 22ND AVE RM 101
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-4400
Practice Address - Country:US
Practice Address - Phone:808-305-9750
Practice Address - Fax:808-733-9154
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI286225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist