Provider Demographics
NPI:1558606707
Name:GODFREY, LAINE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LAINE
Middle Name:
Last Name:GODFREY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2288 OGONTZ AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-5544
Mailing Address - Country:US
Mailing Address - Phone:540-845-8455
Mailing Address - Fax:
Practice Address - Street 1:2288 OGONTZ AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-5544
Practice Address - Country:US
Practice Address - Phone:540-845-8455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH013658225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist