Healthcare Provider Details

I. General information

NPI: 1922579481
Provider Name (Legal Business Name): KRISTY TERESA GODWIN LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date: 05/23/2019
Reactivation Date: 07/12/2024

III. Provider practice location address

13603 MARY BOWIE PKWY
UPPER MARLBORO MD
20774-9075
US

IV. Provider business mailing address

13603 MARY BOWIE PKWY
UPPER MARLBORO MD
20774-9075
US

V. Phone/Fax

Practice location:
  • Phone: 443-898-8282
  • Fax: 443-898-8130
Mailing address:
  • Phone: 443-651-4019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: