Provider Demographics
NPI:1043452295
Name:GOODROAD, KRISTIN DAWN (MSPT)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:DAWN
Last Name:GOODROAD
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:SD
Mailing Address - Zip Code:57013-2617
Mailing Address - Country:US
Mailing Address - Phone:605-764-1480
Mailing Address - Fax:605-987-5631
Practice Address - Street 1:1409 HOLIDAY DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:SD
Practice Address - Zip Code:57013-2617
Practice Address - Country:US
Practice Address - Phone:605-764-1480
Practice Address - Fax:605-987-5631
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0649225100000X
IA004297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist