Healthcare Provider Details

I. General information

NPI: 1801365960
Provider Name (Legal Business Name): ADRIAN AMADOR GODOY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 CABRILLO PARK DR STE 140
SANTA ANA CA
92701-5012
US

IV. Provider business mailing address

3462 PATRITTI AVE
BALDWIN PARK CA
91706-3509
US

V. Phone/Fax

Practice location:
  • Phone: 626-434-6014
  • Fax:
Mailing address:
  • Phone: 626-434-6014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-70494
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: