Provider Demographics
NPI:1023817335
Name:GOODE-ROBERTS, MACKENZIE TILSTON (PT, DPT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:TILSTON
Last Name:GOODE-ROBERTS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:5501 MONTFORT LN
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-9172
Mailing Address - Country:US
Mailing Address - Phone:502-888-3144
Mailing Address - Fax:
Practice Address - Street 1:982 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1566
Practice Address - Country:US
Practice Address - Phone:502-635-6397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0064532251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics