Provider Demographics
NPI:1659705291
Name:GODDARD, AMY LEE (PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LEE
Last Name:GODDARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7634 N BANK RD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-8494
Mailing Address - Country:US
Mailing Address - Phone:207-974-6798
Mailing Address - Fax:
Practice Address - Street 1:2448 W HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2500
Practice Address - Country:US
Practice Address - Phone:541-673-2408
Practice Address - Fax:541-673-2432
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06461225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist