Provider Demographics
NPI:1780125385
Name:GODDIESS, BETHANY ADELINE (AU D CCC-A)
Entity type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:ADELINE
Last Name:GODDIESS
Suffix:
Gender:F
Credentials:AU D CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 WASHINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3405
Mailing Address - Country:US
Mailing Address - Phone:800-328-8602
Mailing Address - Fax:952-285-3980
Practice Address - Street 1:32 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4952
Practice Address - Country:US
Practice Address - Phone:860-629-0781
Practice Address - Fax:860-629-0782
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist