Provider Demographics
NPI:1861562332
Name:GODDARD, AMY LOUISE (PT, CSCS)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:LOUISE
Last Name:GODDARD
Suffix:
Gender:F
Credentials:PT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 S BELT LINE RD STE 140
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-7610
Mailing Address - Country:US
Mailing Address - Phone:972-745-9060
Mailing Address - Fax:972-745-9069
Practice Address - Street 1:1199 S BELT LINE RD STE 140
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-7610
Practice Address - Country:US
Practice Address - Phone:972-745-9060
Practice Address - Fax:972-745-9069
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1101657225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84302TOtherBCBS ID
TX83827EMedicare ID - Type UnspecifiedINDIVIDUAL MEDICARE ID
TX84302TOtherBCBS ID
TXP50610Medicare UPIN