Provider Demographics
NPI:1275839128
Name:GODDARD, MARISA ALANA (CNIM)
Entity Type:Individual
Prefix:MISS
First Name:MARISA
Middle Name:ALANA
Last Name:GODDARD
Suffix:
Gender:F
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11405 WHITE FORGE CT
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77498-0903
Mailing Address - Country:US
Mailing Address - Phone:817-845-7205
Mailing Address - Fax:
Practice Address - Street 1:11405 WHITE FORGE CT
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77498-0903
Practice Address - Country:US
Practice Address - Phone:817-845-7205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2033246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
2033OtherCNIM