Provider Demographics
NPI:1396804449
Name:GOODMAN, KRISTY A (PT)
Entity type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:A
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
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Mailing Address - Street 1:1102 SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4462
Mailing Address - Country:US
Mailing Address - Phone:631-680-3524
Mailing Address - Fax:631-467-4233
Practice Address - Street 1:709 HAWKINS AVE STE 1
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2293
Practice Address - Country:US
Practice Address - Phone:631-467-4221
Practice Address - Fax:631-467-4233
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY026489225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY026489OtherLICENSE