Provider Demographics
NPI:1154701597
Name:GOUDY, CHAD J (PT, DPT, CMTPT)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:J
Last Name:GOUDY
Suffix:
Gender:M
Credentials:PT, DPT, CMTPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:9980 BROOK RD UNIT 16
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-6501
Practice Address - Country:US
Practice Address - Phone:804-550-5730
Practice Address - Fax:804-550-5733
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209518225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1154701597OtherMEDICAID QMB PROVIDER ID
VAC05954OtherGROUP MEDICARE PTAN
VAC05954OtherGROUP MEDICARE PTAN