Provider Demographics
NPI:1609177740
Name:GODINEZ, MIRYAM (MFT - 4153)
Entity Type:Individual
Prefix:MRS
First Name:MIRYAM
Middle Name:
Last Name:GODINEZ
Suffix:
Gender:F
Credentials:MFT - 4153
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 S PECOS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-5828
Mailing Address - Country:US
Mailing Address - Phone:702-379-5421
Mailing Address - Fax:
Practice Address - Street 1:8100 LANCELEAF AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-8126
Practice Address - Country:US
Practice Address - Phone:702-379-5421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-05
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner