Basic Information
| Provider Information | |||||||||
| NPI: | 1326583519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODDARD | ||||||||
| FirstName: | ROCHELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 363 W CUSTER SQ | ||||||||
| Address2: | |||||||||
| City: | ELLETTSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474291963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179873061 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5250 E US HIGHWAY 36 | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461239199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178155501 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2016 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-16-24309 | IN | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.