Healthcare Provider Details

I. General information

NPI: 1063082642
Provider Name (Legal Business Name): KATHRYN E GONCALVES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 W NEW RD
GREENFIELD IN
46140-7304
US

IV. Provider business mailing address

801 N STATE ST
GREENFIELD IN
46140-1270
US

V. Phone/Fax

Practice location:
  • Phone: 317-468-6112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05011470A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: