Basic Information
| Provider Information | |||||||||
| NPI: | 1689273815 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOUDISS | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | KITCHEN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KITCHEN | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | HOPE | ||||||||
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| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5651 FRIST BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370762058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153914545 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2020 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 13157 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT014246 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.