Provider Demographics
NPI:1376298398
Name:GODFREY, THERESA RENEE
Entity type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:RENEE
Last Name:GODFREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 STONEWALL DR
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-3503
Mailing Address - Country:US
Mailing Address - Phone:513-426-3803
Mailing Address - Fax:
Practice Address - Street 1:45 STONEWALL DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-3503
Practice Address - Country:US
Practice Address - Phone:513-426-3803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker