Provider Demographics
NPI:1922602358
Name:GODFREY, MICHAEL BRANDON
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRANDON
Last Name:GODFREY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N MCKINLEY ST STE 520
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3175
Mailing Address - Country:US
Mailing Address - Phone:501-420-0906
Mailing Address - Fax:
Practice Address - Street 1:7505 ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-6000
Practice Address - Country:US
Practice Address - Phone:501-420-0906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR9786-M104100000X
AR9786-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker