Provider Demographics
NPI:1497289730
Name:GODFREY, LEAH KAYE (LCDCI)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:KAYE
Last Name:GODFREY
Suffix:
Gender:F
Credentials:LCDCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7517 CAMERON RD STE 118
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752-2053
Mailing Address - Country:US
Mailing Address - Phone:512-358-4088
Mailing Address - Fax:
Practice Address - Street 1:7517 CAMERON RD STE 118
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-2053
Practice Address - Country:US
Practice Address - Phone:512-358-4088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32171101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)