Basic Information
| Provider Information | |||||||||
| NPI: | 1780125385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODDIESS | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | ADELINE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | AU. D. CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6700 WASHINGTON AVE S | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003288602 | ||||||||
| FaxNumber: | 9522853980 | ||||||||
| Practice Location | |||||||||
| Address1: | 32 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | GROTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063404952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606290781 | ||||||||
| FaxNumber: | 8606290782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2017 | ||||||||
| LastUpdateDate: | 10/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237600000X | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.