Provider Demographics
NPI:1083121214
Name:GODSHALL, SANDRA VIVIANA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:VIVIANA
Last Name:GODSHALL
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 1:1920 TATNALL SQ APT 206
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32966-8017
Mailing Address - Country:US
Mailing Address - Phone:772-766-5309
Mailing Address - Fax:
Practice Address - Street 1:1920 TATNALL SQ APT 206
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32966-8017
Practice Address - Country:US
Practice Address - Phone:772-766-5309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator