Provider Demographics
NPI:1255985446
Name:GODDU, AMANDA (LICSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GODDU
Suffix:
Gender:
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03894-4455
Mailing Address - Country:US
Mailing Address - Phone:603-515-2026
Mailing Address - Fax:
Practice Address - Street 1:240 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOLFEBORO
Practice Address - State:NH
Practice Address - Zip Code:03894-4455
Practice Address - Country:US
Practice Address - Phone:603-515-2066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH27031041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3078870Medicaid