MEDICARE: VICTORIA GODFREY M.ED., IECMH-E

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	222Q00000X	Developmental Therapist		SC
2	171M00000X	Case Manager/Care Coordinator		SC

General Provider Information

NPI Number	:	1912839440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA GODFREY M.ED., IECMH-E

Provider Business Mailing Address
First Line	:	8318 HIBISCUS LN
Second Line	:
City	:	INDIAN LAND
State	:	SC
Zip	:	29707-5022
Country	:	US
Telephone Number	:	704-277-3680
Fax Number	:

Provider Business Practice Location Address
First Line	:	8318 HIBISCUS LN
Second Line	:
City	:	INDIAN LAND
State	:	SC
Zip	:	29707-5022
Country	:	US
Telephone Number	:	704-277-3680
Fax Number	:

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

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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