Provider Demographics
NPI:1821161738
Name:GODDARD, TYLER C (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:C
Last Name:GODDARD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2413
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-2413
Mailing Address - Country:US
Mailing Address - Phone:435-586-2182
Mailing Address - Fax:866-833-5153
Practice Address - Street 1:203 E COBBLECREEK DR
Practice Address - Street 2:SUITE 201
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721-8901
Practice Address - Country:US
Practice Address - Phone:435-586-2182
Practice Address - Fax:866-833-5153
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT373214-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1821161738Medicaid
UT1821161738Medicaid
UT000067626Medicare PIN