Provider Demographics
NPI:1205249976
Name:BANNERT-GODDU, RACHEL (LPC)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:BANNERT-GODDU
Suffix:
Gender:F
Credentials:LPC
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 155
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72757-0155
Mailing Address - Country:US
Mailing Address - Phone:479-310-5640
Mailing Address - Fax:
Practice Address - Street 1:1207 W POPLAR ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-4245
Practice Address - Country:US
Practice Address - Phone:479-310-5640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP2002017101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional