=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255897468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RACHEL MCCABE GOODMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2019
-----------------------------------------------------
Last Update Date | 02/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 61 MAIN ST
-----------------------------------------------------
City | CENTERBROOK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06409-1070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-767-0186
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 71 N HIGH ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06413-1726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-514-2014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 006357
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------