MEDICARE: DR. DALE CHANDES GODBY PHD

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	103TC0700X	Clinical Psychologist	22348	TX

General Provider Information

NPI Number	:	1073633871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALE CHANDES GODBY PHD

Provider Business Mailing Address
First Line	:	6330 LYNDON B JOHNSON FWY STE 150
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75240-6431
Country	:	US
Telephone Number	:	972-233-0648
Fax Number	:

Provider Business Practice Location Address
First Line	:	6330 LYNDON B JOHNSON FWY STE 150
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75240-6431
Country	:	US
Telephone Number	:	972-233-0648
Fax Number	:

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

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	07/08/2007

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