Provider Demographics
NPI:1265501290
Name:GODON, ROLF M (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROLF
Middle Name:M
Last Name:GODON
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:POBOX 3395
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96160
Mailing Address - Country:US
Mailing Address - Phone:530-587-2557
Mailing Address - Fax:530-587-2557
Practice Address - Street 1:10097 RIVERSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161
Practice Address - Country:US
Practice Address - Phone:530-587-2557
Practice Address - Fax:530-587-2557
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY3277103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOPL32770Medicare ID - Type UnspecifiedMEDICARE