Basic Information
| Provider Information | |||||||||
| NPI: | 1578811618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODDARD | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GALVAS | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 227 N DAVISON ST | ||||||||
| Address2: | |||||||||
| City: | DAVISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8105690409 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 303 N. HURSTBOURNE PARKWAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LOUSIVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024125847 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2012 | ||||||||
| LastUpdateDate: | 08/21/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501014308 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.