Provider Demographics
NPI:1205160108
Name:GODWIN, RANDALL R (MED, LISAC)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:R
Last Name:GODWIN
Suffix:
Gender:M
Credentials:MED, LISAC
Other - Prefix:
Other - First Name:RANDALL
Other - Middle Name:R
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, LISAC
Mailing Address - Street 1:2 ACR 3116
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901
Mailing Address - Country:US
Mailing Address - Phone:480-229-0043
Mailing Address - Fax:
Practice Address - Street 1:20 E THOMAS RD STE 2200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3133
Practice Address - Country:US
Practice Address - Phone:844-843-7279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11869101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)