Healthcare Provider Details

I. General information

NPI: 1962008854
Provider Name (Legal Business Name): IRENE JANNETTE GODINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 EL CAMINO REAL STE 213
TUSTIN CA
92780-3656
US

IV. Provider business mailing address

1891 EFFIE ST
LOS ANGELES CA
90026-1711
US

V. Phone/Fax

Practice location:
  • Phone: 714-805-6510
  • Fax:
Mailing address:
  • Phone: 323-644-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number18337
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: