MEDICARE: KRISTIN GODIKSEN P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	002340	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	002340	OTHER	CT	PHYSICAL THERAPY LICENSE

General Provider Information

NPI Number	:	1033291620
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN GODIKSEN P.T.

Provider Business Mailing Address
First Line	:	34 JEROME AVENUEE
Second Line	:	SUITE # 305
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3064
Country	:	US
Telephone Number	:	860-519-1916
Fax Number	:

Provider Business Practice Location Address
First Line	:	34 JEROME AVE
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-2463
Country	:	US
Telephone Number	:	860-519-1916
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	05/09/2014

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