=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497494074
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA LAYNE GODINO LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2022
-----------------------------------------------------
Last Update Date | 02/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 S 4TH ST
-----------------------------------------------------
City | CANADIAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79014-3315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-323-8882
-----------------------------------------------------
Fax | 806-323-6108
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 S 4TH ST
-----------------------------------------------------
City | CANADIAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79014-3315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-323-8882
-----------------------------------------------------
Fax | 806-323-6108
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 107741
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------