Healthcare Provider Details

I. General information

NPI: 1154743946
Provider Name (Legal Business Name): JUAN ANTONIO GODOY CADC II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78140 CALLE TAMPICO
LA QUINTA CA
92253-2900
US

IV. Provider business mailing address

78140 CALLE TAMPICO
LA QUINTA CA
92253-2900
US

V. Phone/Fax

Practice location:
  • Phone: 760-863-7970
  • Fax:
Mailing address:
  • Phone: 760-863-7970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA021740216
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: