Provider Demographics
NPI:1740504398
Name:GODBOLT, QUSAYY M (PHD, BCBA-D)
Entity type:Individual
Prefix:DR
First Name:QUSAYY
Middle Name:M
Last Name:GODBOLT
Suffix:
Gender:M
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 SNOWBALL LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-7855
Mailing Address - Country:US
Mailing Address - Phone:931-378-4751
Mailing Address - Fax:
Practice Address - Street 1:1207 SNOWBALL LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-7855
Practice Address - Country:US
Practice Address - Phone:931-378-4751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1-09-5273103K00000X
TN1-09-5273103K00000X
MO1-09-5273103K00000X
FL1-09-5273103K00000X
1-09-5273103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ024708Medicaid
KY7100405480Medicaid