1023817335 NPI number — MACKENZIE TILSTON GOODE-ROBERTS PT, DPT

Table of content: MACKENZIE TILSTON GOODE-ROBERTS PT, DPT (NPI 1023817335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023817335 NPI number — MACKENZIE TILSTON GOODE-ROBERTS PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODE-ROBERTS
Provider First Name:
MACKENZIE
Provider Middle Name:
TILSTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROBERTS
Provider Other First Name:
MACKENZIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023817335
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5501 MONTFORT LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRESTWOOD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40014-9172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-888-3144
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
982 EASTERN PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40217-1566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-635-6397
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/10/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251P0200X , with the licence number:  006453 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com