Provider Demographics
NPI:1952715674
Name:GODLEY, LISA ANNETTE
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANNETTE
Last Name:GODLEY
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 1:29 MOUNT HOPE PL
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-6160
Mailing Address - Country:US
Mailing Address - Phone:757-582-8787
Mailing Address - Fax:
Practice Address - Street 1:29 MOUNT HOPE PL APT 2
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-6161
Practice Address - Country:US
Practice Address - Phone:757-582-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1607948174400000X
NY564049174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist