Provider Demographics
NPI:1124411392
Name:GODDARD, TERRI
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:
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 1:144 RAILROAD AVE
Mailing Address - Street 2:SUITE 213
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-7207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:144 RAILROAD AVE
Practice Address - Street 2:SUITE 213
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-7207
Practice Address - Country:US
Practice Address - Phone:206-384-2274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60534502172M00000X
WARF60485037173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
No173C00000XOther Service ProvidersReflexologist