Provider Demographics
NPI:1922665363
Name:GODDARD, STEPHANIE M
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:GODDARD
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 1:621 IOWA AVE APT A
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-4787
Mailing Address - Country:US
Mailing Address - Phone:716-983-9699
Mailing Address - Fax:
Practice Address - Street 1:17230 JACKSON CREEK PKWY STE 220
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-7304
Practice Address - Country:US
Practice Address - Phone:719-597-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician