Provider Demographics
NPI:1790035913
Name:GODDARD, AUTUMN JEANETTE (MS)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:JEANETTE
Last Name:GODDARD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:NY
Mailing Address - Zip Code:12831-1800
Mailing Address - Country:US
Mailing Address - Phone:518-306-5246
Mailing Address - Fax:518-233-0703
Practice Address - Street 1:597 3RD AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182-2509
Practice Address - Country:US
Practice Address - Phone:518-233-0544
Practice Address - Fax:518-233-0703
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist