Healthcare Provider Details

I. General information

NPI: 1659962652
Provider Name (Legal Business Name): BLANCA GODINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 S STATE ST STE 6
SAN JACINTO CA
92583-4924
US

IV. Provider business mailing address

25765 ECHO VALLEY RD
HOMELAND CA
92548-9619
US

V. Phone/Fax

Practice location:
  • Phone: 951-654-6002
  • Fax:
Mailing address:
  • Phone: 951-293-9455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1571920724
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126624
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: