Provider Demographics
NPI:1952747107
Name:GODBOLT, TIFFANY RENEE (PTA)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:RENEE
Last Name:GODBOLT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 KINNEY CT
Mailing Address - Street 2:
Mailing Address - City:SELLERS
Mailing Address - State:SC
Mailing Address - Zip Code:29592-8001
Mailing Address - Country:US
Mailing Address - Phone:843-758-4738
Mailing Address - Fax:
Practice Address - Street 1:318 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2116
Practice Address - Country:US
Practice Address - Phone:843-374-3353
Practice Address - Fax:843-374-7245
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-15
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1980225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant