MEDICARE: C. DRAVEN GODWIN PSYCHOLOGY

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	103TC2200X	Clinical Child & Adolescent Psychologist	PSY21516	CA

General Provider Information

NPI Number	:	1750830493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C. DRAVEN GODWIN PSYCHOLOGY

Provider Business Mailing Address
First Line	:	4370 TUJUNGA AVE STE 150
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-2753
Country	:	US
Telephone Number	:	310-795-4428
Fax Number	:	818-396-3173

Provider Business Practice Location Address
First Line	:	4370 TUJUNGA AVE STE 150
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-2753
Country	:	US
Telephone Number	:	310-795-4428
Fax Number	:	818-396-3173

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. CHRISTIAN DRAVEN GODWIN
Credential	:	M.ED., PH.D.
Telephone Number	:	323-610-9107

Provider Enumeration Date	:	09/22/2016
Last Update Date	:	09/22/2016

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