=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063593846
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES MITCHELL GODDARD LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 S 6TH AVE
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85723-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-629-1839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2841 N COLUMBUS BLVD # 29
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85712-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-323-3301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LMSW-11983
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------