Provider Demographics
NPI:1154743946
Name:GODOY, JUAN ANTONIO (CADC II)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:ANTONIO
Last Name:GODOY
Suffix:
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78140 CALLE TAMPICO
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-2900
Mailing Address - Country:US
Mailing Address - Phone:760-863-7970
Mailing Address - Fax:
Practice Address - Street 1:78140 CALLE TAMPICO
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-2900
Practice Address - Country:US
Practice Address - Phone:760-863-7970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA021740216101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)