Healthcare Provider Details

I. General information

NPI: 1629612429
Provider Name (Legal Business Name): KYLE GOODWIN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3708 MOUNTAIN RD STE D
PASADENA MD
21122-2025
US

IV. Provider business mailing address

350 NEW FIDELITY CT
GARNER NC
27529-2665
US

V. Phone/Fax

Practice location:
  • Phone: 410-255-4833
  • Fax: 410-255-4834
Mailing address:
  • Phone: 919-258-2714
  • Fax: 410-648-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number27753
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305214077
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: