Provider Demographics
NPI:1578977443
Name:GODDEN, WAYNE II
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:GODDEN
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14320 PALM DRIVE
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-7200
Mailing Address - Country:US
Mailing Address - Phone:760-773-6834
Mailing Address - Fax:
Practice Address - Street 1:14320 PALM DRIVE
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-7200
Practice Address - Country:US
Practice Address - Phone:760-773-6834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)