Healthcare Provider Details

I. General information

NPI: 1255817326
Provider Name (Legal Business Name): KRISTIN GODIKSEN PHYSICAL THERAPY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 JEROME AVE STE 305
BLOOMFIELD CT
06002-2463
US

IV. Provider business mailing address

34 JEROME AVE STE 305
BLOOMFIELD CT
06002-2463
US

V. Phone/Fax

Practice location:
  • Phone: 860-431-0902
  • Fax:
Mailing address:
  • Phone: 860-431-0902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number002340
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KRISTIN GODIKSEN
Title or Position: MEMBER
Credential: PT, IMTC
Phone: 860-930-8230