Provider Demographics
NPI:1659833374
Name:GODINEZ, MIREYA
Entity Type:Individual
Prefix:MRS
First Name:MIREYA
Middle Name:
Last Name:GODINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-4022
Mailing Address - Country:US
Mailing Address - Phone:510-875-3736
Mailing Address - Fax:
Practice Address - Street 1:400 29TH ST STE 204
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3547
Practice Address - Country:US
Practice Address - Phone:510-679-3545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician