Provider Demographics
NPI:1700540200
Name:GODDARD, KELLY AMANDA
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:AMANDA
Last Name:GODDARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 NICHOLS TER
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-3959
Mailing Address - Country:US
Mailing Address - Phone:203-377-1752
Mailing Address - Fax:
Practice Address - Street 1:201 NICHOLS TER
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-3959
Practice Address - Country:US
Practice Address - Phone:203-377-1752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2024-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT18512255A2300X
CT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program