Basic Information
Provider Information | |||||||||
NPI: | 1386879856 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GODSEY | ||||||||
FirstName: | MICHAELA | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMHC, SUDP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEWIS | ||||||||
OtherFirstName: | MICHAELA | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2569 | ||||||||
Address2: |   | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982130569 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4254935816 | ||||||||
FaxNumber: | 4254935801 | ||||||||
Practice Location | |||||||||
Address1: | 25959 COMMUNITY PLAZA WAY | ||||||||
Address2: |   | ||||||||
City: | SEDRO WOOLLEY | ||||||||
State: | WA | ||||||||
PostalCode: | 982849721 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608547067 | ||||||||
FaxNumber: | 3608547060 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2009 | ||||||||
LastUpdateDate: | 01/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 101YM0800X | 60100253 | WA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | LH60815972 | 01 | WA | LICENSED MENTAL HEALTH THERAPIST | OTHER | CP60366824 | 01 | WA | SUBSTANCE USE DISORDER PROFESSIONAL | OTHER |