Provider Demographics
NPI:1942035142
Name:GODDARD, MICHELLE (RADT-I)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GODDARD
Suffix:
Gender:F
Credentials:RADT-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 39TH ST APT 533
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3071
Mailing Address - Country:US
Mailing Address - Phone:415-324-0408
Mailing Address - Fax:
Practice Address - Street 1:2323 HEARST AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1319
Practice Address - Country:US
Practice Address - Phone:510-548-7270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)