Healthcare Provider Details

I. General information

NPI: 1629667522
Provider Name (Legal Business Name): BRYAN GODOY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 W WHITES BRIDGE AVE
FRESNO CA
93706-1225
US

IV. Provider business mailing address

3855 N WEST AVE STE 110
FRESNO CA
93705-2759
US

V. Phone/Fax

Practice location:
  • Phone: 559-264-5096
  • Fax:
Mailing address:
  • Phone: 559-334-6433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1457530222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: