Basic Information
| Provider Information | |||||||||
| NPI: | 1770864936 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODOY | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 N STATE ST STE D | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925432960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517913350 | ||||||||
| FaxNumber: | 9517913353 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 N STATE ST STE D | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925431485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517913350 | ||||||||
| FaxNumber: | 9517913353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2011 | ||||||||
| LastUpdateDate: | 08/25/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 333903 | 05 | CA | MEDICAID | 333901 | 05 | CA | MEDICAID |