Provider Demographics
NPI:1255548632
Name:GODEK, MARTIN JOHN (LMHC)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:JOHN
Last Name:GODEK
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 DEER RD
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4963
Mailing Address - Country:US
Mailing Address - Phone:631-981-7616
Mailing Address - Fax:
Practice Address - Street 1:56 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8327
Practice Address - Country:US
Practice Address - Phone:516-770-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000091101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health