Provider Demographics
NPI:1871750232
Name:GODDARD, KIRK JUDE DOUGLAS (MA, LLP)
Entity type:Individual
Prefix:MR
First Name:KIRK JUDE
Middle Name:DOUGLAS
Last Name:GODDARD
Suffix:
Gender:M
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2573
Mailing Address - Country:US
Mailing Address - Phone:248-318-7985
Mailing Address - Fax:
Practice Address - Street 1:28303 JOY RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-5524
Practice Address - Country:US
Practice Address - Phone:734-513-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007324103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical