Healthcare Provider Details

I. General information

NPI: 1023817335
Provider Name (Legal Business Name): MACKENZIE TILSTON GOODE-ROBERTS PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MACKENZIE ROBERTS PT, DPT

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 EASTERN PKWY
LOUISVILLE KY
40217-1566
US

IV. Provider business mailing address

5501 MONTFORT LN
CRESTWOOD KY
40014-9172
US

V. Phone/Fax

Practice location:
  • Phone: 502-635-6397
  • Fax:
Mailing address:
  • Phone: 502-888-3144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number006453
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: