Provider Demographics
NPI:1881578672
Name:GODDARD, TRAVIS ANTHONY (EDS, PPS)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:ANTHONY
Last Name:GODDARD
Suffix:
Gender:M
Credentials:EDS, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 E AMAR RD APT 83
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-1716
Mailing Address - Country:US
Mailing Address - Phone:909-498-6595
Mailing Address - Fax:
Practice Address - Street 1:1901 DESIRE AVE
Practice Address - Street 2:
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748-3846
Practice Address - Country:US
Practice Address - Phone:626-964-2358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool