=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912777590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN GODDARD CHW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2024
-----------------------------------------------------
Last Update Date | 03/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PO BOX 546
-----------------------------------------------------
City | GRESHAM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97030-0132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-373-4165
-----------------------------------------------------
Fax | 971-373-4165
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 546
-----------------------------------------------------
City | GRESHAM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97030-0132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number | THW000110230
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------