Provider Demographics
NPI:1356619373
Name:GOODINE, CORRIE (DPT)
Entity type:Individual
Prefix:
First Name:CORRIE
Middle Name:
Last Name:GOODINE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 N KAY DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-4331
Mailing Address - Country:US
Mailing Address - Phone:920-980-5431
Mailing Address - Fax:
Practice Address - Street 1:N7135 ROCKY KNOLL PKWY
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-3103
Practice Address - Country:US
Practice Address - Phone:920-449-1254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10914-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10914-024OtherPHYSICAL THERAPIST LICENSE