Provider Demographics
NPI:1295212504
Name:GODDARD, NADINE MARIE
Entity type:Individual
Prefix:
First Name:NADINE
Middle Name:MARIE
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 1:5343 BARSTOW ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-2204
Mailing Address - Country:US
Mailing Address - Phone:619-209-1915
Mailing Address - Fax:
Practice Address - Street 1:4141 PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2030
Practice Address - Country:US
Practice Address - Phone:209-861-9393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)