Provider Demographics
NPI:1184363921
Name:GODUSKY, KIERA ELYSSE (OTR/L)
Entity type:Individual
Prefix:
First Name:KIERA
Middle Name:ELYSSE
Last Name:GODUSKY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6490 AMBROSIA DR APT 5203
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3146
Mailing Address - Country:US
Mailing Address - Phone:610-969-8210
Mailing Address - Fax:
Practice Address - Street 1:11838 BERNARDO PLAZA CT UNIT 10
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2413
Practice Address - Country:US
Practice Address - Phone:858-673-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23160225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist