Provider Demographics
NPI:1942951736
Name:GODDERIDGE, ALEX CHARLES (DPT)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:CHARLES
Last Name:GODDERIDGE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 S. VALLEY DR. STE A #178
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686
Mailing Address - Country:US
Mailing Address - Phone:208-800-1619
Mailing Address - Fax:
Practice Address - Street 1:12072 W MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2462
Practice Address - Country:US
Practice Address - Phone:208-939-0533
Practice Address - Fax:208-939-3341
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-7679225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT-7679OtherSTATE LICENSE