Healthcare Provider Details

I. General information

NPI: 1780378604
Provider Name (Legal Business Name): STEPHANIE Y GODMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HOLSTON DR
GREENEVILLE TN
37743-3127
US

IV. Provider business mailing address

1167 SPRATLIN PARK DR
GRAY TN
37615-6205
US

V. Phone/Fax

Practice location:
  • Phone: 423-639-1104
  • Fax: 423-636-8365
Mailing address:
  • Phone: 234-673-6004
  • Fax: 423-467-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0000008483
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8483
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: