Healthcare Provider Details

I. General information

NPI: 1487338406
Provider Name (Legal Business Name): KENDALL GODT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2539 MIDDLE COUNTRY RD
CENTEREACH NY
11720-3551
US

IV. Provider business mailing address

645 BELLE TERRE RD APT 76
PORT JEFFERSON NY
11777-1943
US

V. Phone/Fax

Practice location:
  • Phone: 631-737-6434
  • Fax:
Mailing address:
  • Phone: 631-848-9213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number796294
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF405021-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: