Provider Demographics
NPI:1114470952
Name:GODDARD, MOLLY (DNP, PMHNP)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:
Last Name:GODDARD
Suffix:
Gender:F
Credentials:DNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1422
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-0098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3407 S CORBETT AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4621
Practice Address - Country:US
Practice Address - Phone:503-272-1009
Practice Address - Fax:971-279-7512
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OR201507180RN163W00000X
OR201705849NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No163W00000XNursing Service ProvidersRegistered Nurse