Provider Demographics
NPI:1588109482
Name:GODDARD, RICHARD RAY JR (PMHNP-BC, LPCC)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:RAY
Last Name:GODDARD
Suffix:JR
Gender:
Credentials:PMHNP-BC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S MAIN CROSS ST
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-1065
Mailing Address - Country:US
Mailing Address - Phone:606-638-0938
Mailing Address - Fax:
Practice Address - Street 1:203 S WATER ST
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1347
Practice Address - Country:US
Practice Address - Phone:606-649-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-30
Last Update Date:2025-04-22
Deactivation Date:2025-04-07
Deactivation Code:
Reactivation Date:2025-04-21
Provider Licenses
StateLicense IDTaxonomies
KY262574101YM0800X
KY4036771363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health