Basic Information
| Provider Information | |||||||||
| NPI: | 1609844513 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOUDEY | ||||||||
| FirstName: | SKY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3760 CONVOY ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882088526 | ||||||||
| FaxNumber: | 8587510901 | ||||||||
| Practice Location | |||||||||
| Address1: | 72840 HIGHWAY 111 STE A-150 | ||||||||
| Address2: | |||||||||
| City: | PALM DESERT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922603324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586146332 | ||||||||
| FaxNumber: | 8586146324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 05/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00002582 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT292957 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 18397 | 01 | WA | L&I | OTHER | 7270200 | 05 | WA | MEDICAID |