Provider Demographics
NPI:1659585404
Name:GODFREY, ADAM ROBERT (SSP, NASP)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:ROBERT
Last Name:GODFREY
Suffix:
Gender:M
Credentials:SSP, NASP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13801 E BENSON HWY
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-9074
Mailing Address - Country:US
Mailing Address - Phone:520-879-2440
Mailing Address - Fax:
Practice Address - Street 1:13801 E BENSON HWY
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-9074
Practice Address - Country:US
Practice Address - Phone:520-879-2440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3690822103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ968224Medicaid