Provider Demographics
NPI:1245824911
Name:GODBOLD, LIANA BROOKE (PTA)
Entity type:Individual
Prefix:MISS
First Name:LIANA
Middle Name:BROOKE
Last Name:GODBOLD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 NW VETERANS ST APT 304
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-2809
Mailing Address - Country:US
Mailing Address - Phone:386-365-8826
Mailing Address - Fax:
Practice Address - Street 1:560 SW MCFARLANE AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5614
Practice Address - Country:US
Practice Address - Phone:386-758-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30806225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant