Healthcare Provider Details

I. General information

NPI: 1962488403
Provider Name (Legal Business Name): MARY MCLAIN GODIN MA, LPA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16581 US HWY 17 N SUITE 600
HAMPSTEAD NC
28443-7451
US

IV. Provider business mailing address

16581 US HWY 17 N SUITE 600
HAMPSTEAD NC
28443-7451
US

V. Phone/Fax

Practice location:
  • Phone: 910-270-9995
  • Fax: 910-270-9905
Mailing address:
  • Phone: 910-270-9995
  • Fax: 910-270-9905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2335
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4801-LPC
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2335-LPA
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: