Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | NY |
NPI | 1235270091 |
---|---|
Provider Name | Mr. Brian Godbout |
First Address | East Islip, NY 11730 |
Second Address | East Islip, NY 11730-3511 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2007 |
Last Update Date | 11/09/2017 |