Provider Demographics
NPI:1215256763
Name:GODDARD, KRISTEN FOWLES (CADC)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:FOWLES
Last Name:GODDARD
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:DOVER FOXCROFT
Mailing Address - State:ME
Mailing Address - Zip Code:04426-1270
Mailing Address - Country:US
Mailing Address - Phone:207-564-4110
Mailing Address - Fax:207-564-4478
Practice Address - Street 1:897 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:DOVER-FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426
Practice Address - Country:US
Practice Address - Phone:207-564-4110
Practice Address - Fax:207-564-4478
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC3851170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS