Provider Demographics
NPI:1598246027
Name:GODWIN, DAERICCA JANAE
Entity Type:Individual
Prefix:
First Name:DAERICCA
Middle Name:JANAE
Last Name:GODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 MASHBURN RD
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32448-5486
Mailing Address - Country:US
Mailing Address - Phone:850-272-4520
Mailing Address - Fax:
Practice Address - Street 1:4295 5TH AVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2176
Practice Address - Country:US
Practice Address - Phone:850-482-8091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31859225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist