Healthcare Provider Details

I. General information

NPI: 1912839440
Provider Name (Legal Business Name): VICTORIA GODFREY M.ED., IECMH-E
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8318 HIBISCUS LN
INDIAN LAND SC
29707-5022
US

IV. Provider business mailing address

8318 HIBISCUS LN
INDIAN LAND SC
29707-5022
US

V. Phone/Fax

Practice location:
  • Phone: 704-277-3680
  • Fax:
Mailing address:
  • Phone: 704-277-3680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: