Provider Demographics
NPI:1013536432
Name:GODLEY, WANDA RUBY (LMT)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:RUBY
Last Name:GODLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 SEA ISLAND PKWY STE 16
Mailing Address - Street 2:
Mailing Address - City:LADYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29907-1460
Mailing Address - Country:US
Mailing Address - Phone:843-812-4758
Mailing Address - Fax:
Practice Address - Street 1:73 SEA ISLAND PKWY STE 16
Practice Address - Street 2:
Practice Address - City:LADYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29907-1460
Practice Address - Country:US
Practice Address - Phone:843-812-4758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3078225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist