MEDICARE: WILLIAM BLAKE GODFREY SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP-564	NV

General Provider Information

NPI Number	:	1053436386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM BLAKE GODFREY SLP

Provider Business Mailing Address
First Line	:	1957 LARKSPUR RANCH CT
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89012-3438
Country	:	US
Telephone Number	:	702-561-8209
Fax Number	:

Provider Business Practice Location Address
First Line	:	1957 LARKSPUR RANCH CT
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89012-3438
Country	:	US
Telephone Number	:	702-561-8209
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	01/09/2009

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