Provider Demographics
NPI:1326583519
Name:GODDARD, ROCHELLE (BCBA)
Entity Type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:
Last Name:GODDARD
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 W CUSTER SQ
Mailing Address - Street 2:
Mailing Address - City:ELLETTSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47429-1963
Mailing Address - Country:US
Mailing Address - Phone:317-987-3061
Mailing Address - Fax:
Practice Address - Street 1:5250 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9199
Practice Address - Country:US
Practice Address - Phone:317-815-5501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-27
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-16-24309103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst