Provider Demographics
NPI:1033444286
Name:GODDARD, DIANE MARIE (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MARIE
Last Name:GODDARD
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:FRIESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:6800 PARK TEN BLVD STE 200S
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-4293
Mailing Address - Country:US
Mailing Address - Phone:210-287-4472
Mailing Address - Fax:210-261-1821
Practice Address - Street 1:8122 DATAPOINT DR STE 1003
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3273
Practice Address - Country:US
Practice Address - Phone:210-261-1500
Practice Address - Fax:210-261-1837
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX256951363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health