Provider Demographics
NPI:1245498575
Name:GODBOLE, PRAJAKTA
Entity type:Individual
Prefix:
First Name:PRAJAKTA
Middle Name:
Last Name:GODBOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115A TOWN AND COUNTRY DR # A
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-3924
Mailing Address - Country:US
Mailing Address - Phone:026-837-0505
Mailing Address - Fax:
Practice Address - Street 1:115 TOWN AND COUNTRY DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-3960
Practice Address - Country:US
Practice Address - Phone:925-837-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46525106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health