Provider Demographics
NPI:1861904682
Name:GOFORTH, KIERSTIN
Entity type:Individual
Prefix:
First Name:KIERSTIN
Middle Name:
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIERSTIN
Other - Middle Name:
Other - Last Name:HAMLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1701 LIBRARY BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-1567
Mailing Address - Country:US
Mailing Address - Phone:317-881-9965
Mailing Address - Fax:
Practice Address - Street 1:1701 LIBRARY BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142
Practice Address - Country:US
Practice Address - Phone:317-881-9965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006007A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty