Provider Demographics
NPI:1447827589
Name:GODFREY, THERON COOPER II
Entity type:Individual
Prefix:
First Name:THERON
Middle Name:COOPER
Last Name:GODFREY
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1964 ASHLEY RIVER RD UNIT 80901B
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29416-1637
Mailing Address - Country:US
Mailing Address - Phone:843-246-4322
Mailing Address - Fax:888-808-4249
Practice Address - Street 1:1964 ASHLEY RIVER RD UNIT 80901B
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29416-1637
Practice Address - Country:US
Practice Address - Phone:843-246-4322
Practice Address - Fax:888-808-4249
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician