Provider Demographics
NPI:1275130304
Name:GODWIN, MATTHEW JOHN (SUDRC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:GODWIN
Suffix:
Gender:M
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11540 MARSH CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:CA
Mailing Address - Zip Code:94517-9759
Mailing Address - Country:US
Mailing Address - Phone:925-672-5700
Mailing Address - Fax:925-672-1374
Practice Address - Street 1:11540 MARSH CREEK RD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:CA
Practice Address - Zip Code:94517-9759
Practice Address - Country:US
Practice Address - Phone:925-672-5700
Practice Address - Fax:925-672-1374
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)