Provider Demographics
NPI:1023638590
Name:GOODLETT, PEYTON M (MS, OT)
Entity type:Individual
Prefix:
First Name:PEYTON
Middle Name:M
Last Name:GOODLETT
Suffix:
Gender:F
Credentials:MS, OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 BARDSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1916
Mailing Address - Country:US
Mailing Address - Phone:502-459-4647
Mailing Address - Fax:
Practice Address - Street 1:4707 HUNTERS POINT CIR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-1421
Practice Address - Country:US
Practice Address - Phone:502-836-4363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100665540Medicaid