Provider Demographics
NPI:1053814871
Name:GODBOLD, DIOSELINA RUIZ (MA, LPCI, CT)
Entity Type:Individual
Prefix:
First Name:DIOSELINA
Middle Name:RUIZ
Last Name:GODBOLD
Suffix:
Gender:F
Credentials:MA, LPCI, CT
Other - Prefix:
Other - First Name:DIO
Other - Middle Name:
Other - Last Name:GODBOLD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1468 AVALON DR
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-5444
Mailing Address - Country:US
Mailing Address - Phone:843-798-0427
Mailing Address - Fax:
Practice Address - Street 1:12117 OCEAN HWY
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-7941
Practice Address - Country:US
Practice Address - Phone:843-237-8231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-18
Last Update Date:2018-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6707101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional