Provider Demographics
NPI:1528111242
Name:GODFREY, ANGELA S (MS,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:S
Last Name:GODFREY
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25001 STATE LINE RD
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-8351
Mailing Address - Country:US
Mailing Address - Phone:122-836-9649
Mailing Address - Fax:228-460-5120
Practice Address - Street 1:7302 HIGHWAY 613
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-9373
Practice Address - Country:US
Practice Address - Phone:228-369-6493
Practice Address - Fax:228-460-5120
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3504235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS12084074OtherAMERICAN SPEECH AND HEARING ASSOCIATION
MSS3504OtherMS SLP LICENSE