Provider Demographics
NPI:1558122432
Name:GODDARD, SADIE R
Entity Type:Individual
Prefix:
First Name:SADIE
Middle Name:R
Last Name:GODDARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SADIE
Other - Middle Name:R
Other - Last Name:GODDARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:472 BALLAINE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-6550
Mailing Address - Country:US
Mailing Address - Phone:907-712-7414
Mailing Address - Fax:
Practice Address - Street 1:472 BALLAINE RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-6550
Practice Address - Country:US
Practice Address - Phone:907-712-7414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK203953235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist