Provider Demographics
NPI:1740014125
Name:GODDARD, ALEXIS (BCBA)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:GODDARD
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 TRUCK RTE
Mailing Address - Street 2:
Mailing Address - City:ALBURGH
Mailing Address - State:VT
Mailing Address - Zip Code:05440-9105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6214 24TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-3319
Practice Address - Country:US
Practice Address - Phone:802-734-8895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst