Provider Demographics
NPI:1023029170
Name:GODFREY, JOHN PHILLIP (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PHILLIP
Last Name:GODFREY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 152680
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78715-2680
Mailing Address - Country:US
Mailing Address - Phone:512-292-1122
Mailing Address - Fax:512-292-1144
Practice Address - Street 1:5750 BALCONES DR STE 106
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4268
Practice Address - Country:US
Practice Address - Phone:737-202-5789
Practice Address - Fax:737-209-7080
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25101103T00000X, 103TA0700X, 103TB0200X, 103TC2200X, 103TF0000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160306OtherVALUE OPTIONS
TX040973202Medicaid
TX0003LJOtherBCBS NUMBER
TX97034000OtherMAGELLAN ID NUMBER
TX160306OtherVALUE OPTIONS