Healthcare Provider Details

I. General information

NPI: 1699747428
Provider Name (Legal Business Name): MICHELLE MARIE GODEK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: MICHELLE MARIE MILLER ATC

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

OHIO UNIVERSITY PEDEN TOWER RM 118
ATHENS OH
45701
US

IV. Provider business mailing address

10010 ALDERMAN RD
MILLFIELD OH
45761-9639
US

V. Phone/Fax

Practice location:
  • Phone: 740-593-1195
  • Fax:
Mailing address:
  • Phone: 740-591-3538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001596
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: