Provider Demographics
NPI:1588199541
Name:GODINEZ, MARIO (CADCII, CDVC, CAMS)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:GODINEZ
Suffix:
Gender:M
Credentials:CADCII, CDVC, CAMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10953 RAMONA BLVD
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-2629
Mailing Address - Country:US
Mailing Address - Phone:626-434-2723
Mailing Address - Fax:626-279-2532
Practice Address - Street 1:10953 RAMONA BLVD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-1319
Practice Address - Country:US
Practice Address - Phone:626-434-2723
Practice Address - Fax:626-279-2532
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC25171214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70567FMedicare Oscar/Certification