Provider Demographics
NPI:1497494074
Name:GODINO, TINA (LSW)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:GODINO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CANADIAN
Mailing Address - State:TX
Mailing Address - Zip Code:79014-3315
Mailing Address - Country:US
Mailing Address - Phone:806-323-8882
Mailing Address - Fax:
Practice Address - Street 1:1010 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CANADIAN
Practice Address - State:TX
Practice Address - Zip Code:79014-3315
Practice Address - Country:US
Practice Address - Phone:806-323-8882
Practice Address - Fax:806-323-6108
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107741104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker