Basic Information
| Provider Information | |||||||||
| NPI: | 1619624699 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GODFREY | ||||||||
| FirstName: | DEANNA | ||||||||
| MiddleName: | MILLER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 SUNSET CT | ||||||||
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| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296428770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645617413 | ||||||||
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| Practice Location | |||||||||
| Address1: | 311 SIMPSON RD | ||||||||
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| City: | ANDERSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296212157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642613875 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2022 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 1170 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.