Basic Information
| Provider Information | |||||||||
| NPI: | 1356619373 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODINE | ||||||||
| FirstName: | CORRIE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 N KAY DR | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530834331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209805431 | ||||||||
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| Practice Location | |||||||||
| Address1: | N7135 ROCKY KNOLL PKWY | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530733103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204491254 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2011 | ||||||||
| LastUpdateDate: | 12/05/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10914-024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 10914-024 | 01 | WI | PHYSICAL THERAPIST LICENSE | OTHER |