Provider Demographics
NPI:1174630065
Name:GODFREY, STEPHEN GREGG (PSYD,NCC,LMHC)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:GREGG
Last Name:GODFREY
Suffix:
Gender:M
Credentials:PSYD,NCC,LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 S WASHINGTON AVE STE D
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-4292
Mailing Address - Country:US
Mailing Address - Phone:321-567-4903
Mailing Address - Fax:321-567-4904
Practice Address - Street 1:1313 S WASHINGTON AVE STE D
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-4292
Practice Address - Country:US
Practice Address - Phone:321-567-4903
Practice Address - Fax:321-567-4904
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLMHC6545101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20-1237216OtherTAX ID
10746677OtherCAQH