Healthcare Provider Details

I. General information

NPI: 1770864936
Provider Name (Legal Business Name): LISA MARIE GODOY CADC-CAS CS12540919
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N STATE ST
HEMET CA
92543-1474
US

IV. Provider business mailing address

3525 PRESLEY AVE
RIVERSIDE CA
92507-4453
US

V. Phone/Fax

Practice location:
  • Phone: 951-522-2668
  • Fax: 951-715-5060
Mailing address:
  • Phone: 951-782-2400
  • Fax: 951-715-5060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCS12540919
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCS12540919
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: