Healthcare Provider Details

I. General information

NPI: 1114271590
Provider Name (Legal Business Name): GRACE MARY GODINO MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 BIRCH RD
BOLINAS CA
94924
US

IV. Provider business mailing address

PO BOX 786
BOLINAS CA
94924-0786
US

V. Phone/Fax

Practice location:
  • Phone: 415-949-7631
  • Fax:
Mailing address:
  • Phone: 415-328-3880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number44840
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: