Provider Demographics
NPI:1578811618
Name:GODDARD, ANDREA LYNN (DPT)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LYNN
Last Name:GODDARD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:LYNN
Other - Last Name:GALVAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:227 N DAVISON ST
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423
Mailing Address - Country:US
Mailing Address - Phone:810-569-0409
Mailing Address - Fax:
Practice Address - Street 1:303 N. HURSTBOURNE PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUSIVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222
Practice Address - Country:US
Practice Address - Phone:502-412-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014308225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist