Provider Demographics
NPI:1003354663
Name:GODDARD, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GODDARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 EDGEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SPRING CREEK
Mailing Address - State:NV
Mailing Address - Zip Code:89815-5709
Mailing Address - Country:US
Mailing Address - Phone:775-401-1439
Mailing Address - Fax:
Practice Address - Street 1:415 US HIGHWAY 95A S
Practice Address - Street 2:SUITE 702G
Practice Address - City:FERNLEY
Practice Address - State:NV
Practice Address - Zip Code:89408-9261
Practice Address - Country:US
Practice Address - Phone:775-575-2284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health