Provider Demographics
NPI:1760769384
Name:GODFREY, MARY JANE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY JANE
Middle Name:
Last Name:GODFREY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 SPRUCE STREET
Mailing Address - Street 2:
Mailing Address - City:NORTH COLLINS
Mailing Address - State:NY
Mailing Address - Zip Code:14111
Mailing Address - Country:US
Mailing Address - Phone:716-842-0440
Mailing Address - Fax:716-842-4069
Practice Address - Street 1:2107 SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:NORTH COLLINS
Practice Address - State:NY
Practice Address - Zip Code:14111
Practice Address - Country:US
Practice Address - Phone:716-842-0440
Practice Address - Fax:716-842-4069
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085183104100000X
NY0841191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1760769384Medicaid