Provider Demographics
NPI:1619624699
Name:GODFREY, DEANNA MILLER
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:MILLER
Last Name:GODFREY
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 1:105 SUNSET CT
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-8770
Mailing Address - Country:US
Mailing Address - Phone:864-561-7413
Mailing Address - Fax:
Practice Address - Street 1:311 SIMPSON RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2157
Practice Address - Country:US
Practice Address - Phone:864-261-3875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1170225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant