Provider Demographics
NPI:1770864936
Name:GODOY, LISA MARIE (CADC-CAS CS12540919)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:GODOY
Suffix:
Gender:F
Credentials:CADC-CAS CS12540919
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 PRESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-4453
Mailing Address - Country:US
Mailing Address - Phone:951-782-2400
Mailing Address - Fax:951-715-5060
Practice Address - Street 1:3525 PRESLEY AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-4453
Practice Address - Country:US
Practice Address - Phone:951-782-2400
Practice Address - Fax:951-715-5060
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACS12540919101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA333903Medicaid
CA333901Medicaid