Healthcare Provider Details

I. General information

NPI: 1679848063
Provider Name (Legal Business Name): KRISTEN LEE GODENICK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 W EADS PKWY
LAWRENCEBURG IN
47025-1139
US

IV. Provider business mailing address

427 W EADS PKWY
LAWRENCEBURG IN
47025-1139
US

V. Phone/Fax

Practice location:
  • Phone: 812-537-7375
  • Fax: 812-537-5271
Mailing address:
  • Phone: 812-537-7375
  • Fax: 812-537-5271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2961-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: