Healthcare Provider Details

I. General information

NPI: 1528260676
Provider Name (Legal Business Name): TIFFANY NICOLE GODWIN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15411 W WADDELL RD STE 102-1073
SURPRISE AZ
85379-5170
US

IV. Provider business mailing address

15411 W WADDELL RD STE 102-1073
SURPRISE AZ
85379-5170
US

V. Phone/Fax

Practice location:
  • Phone: 850-739-2332
  • Fax: 623-632-0097
Mailing address:
  • Phone: 850-739-2332
  • Fax: 623-632-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY005014
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: