Provider Demographics
NPI:1053042226
Name:GODDARD, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
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 1:2121 S 125TH EAST AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-5800
Mailing Address - Country:US
Mailing Address - Phone:191-857-4844
Mailing Address - Fax:
Practice Address - Street 1:2121 S 125TH EAST AVE STE 106
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-5800
Practice Address - Country:US
Practice Address - Phone:191-857-4844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator