Provider Demographics
NPI:1639649791
Name:GODBOLT, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GODBOLT
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 1:1123 SANDY BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:MULLINS
Mailing Address - State:SC
Mailing Address - Zip Code:29574-4215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1123 SANDY BLUFF RD
Practice Address - Street 2:
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-4215
Practice Address - Country:US
Practice Address - Phone:843-464-3760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC45-5423078Medicaid