Healthcare Provider Details

I. General information

NPI: 1861157877
Provider Name (Legal Business Name): BRENAN R GODFREY RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2021
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 N GATEWAY DR
PROVIDENCE UT
84332-9707
US

IV. Provider business mailing address

87 S MAIN ST
CLARKSTON UT
84305-7732
US

V. Phone/Fax

Practice location:
  • Phone: 435-915-6927
  • Fax: 435-220-2030
Mailing address:
  • Phone: 801-655-4950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number14176565-3902
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: