Provider Demographics
NPI:1295488591
Name:GODDARD, BRADLEY RAY
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:RAY
Last Name:GODDARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 NW 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-2713
Mailing Address - Country:US
Mailing Address - Phone:971-219-5691
Mailing Address - Fax:
Practice Address - Street 1:660 NW 9TH AVE
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-2713
Practice Address - Country:US
Practice Address - Phone:971-219-5691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty