Provider Demographics
NPI:1366503419
Name:GODFREY, ANN C (PT CMDT)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:C
Last Name:GODFREY
Suffix:
Gender:F
Credentials:PT CMDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2838 ANDREW ST
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567
Mailing Address - Country:US
Mailing Address - Phone:228-762-2345
Mailing Address - Fax:228-762-2365
Practice Address - Street 1:2838 ANDREW ST
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567
Practice Address - Country:US
Practice Address - Phone:228-762-2345
Practice Address - Fax:228-762-2365
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016039Medicaid
MS01886265Medicaid
MS09016039Medicaid