Provider Demographics
NPI:1356937528
Name:GODDARD, MACKENZIE ROSE (OTR/L)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ROSE
Last Name:GODDARD
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 1:9 N CAVESSON DR
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-9665
Mailing Address - Country:US
Mailing Address - Phone:609-335-3534
Mailing Address - Fax:
Practice Address - Street 1:1135 OLDE W CHOCOLATE AVE
Practice Address - Street 2:
Practice Address - City:HUMMELSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17036-9188
Practice Address - Country:US
Practice Address - Phone:717-832-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC017046225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist