Provider Demographics
NPI:1144609264
Name:GODDARD, STEPHEN DAYTON
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DAYTON
Last Name:GODDARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 VALLEY MANOR LN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26187-8260
Mailing Address - Country:US
Mailing Address - Phone:304-375-1990
Mailing Address - Fax:
Practice Address - Street 1:282 VALLEY MANOR LN
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:WV
Practice Address - Zip Code:26187-8260
Practice Address - Country:US
Practice Address - Phone:304-375-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT7749225100000X
WVPT1602225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist