Provider Demographics
NPI:1114271590
Name:GODINO, GRACE MARY (MFT)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:MARY
Last Name:GODINO
Suffix:
Gender:F
Credentials:MFT
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 786
Mailing Address - Street 2:
Mailing Address - City:BOLINAS
Mailing Address - State:CA
Mailing Address - Zip Code:94924-0786
Mailing Address - Country:US
Mailing Address - Phone:415-328-3880
Mailing Address - Fax:
Practice Address - Street 1:1939 DIVISADERO ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2507
Practice Address - Country:US
Practice Address - Phone:415-686-5457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44840106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist