Provider Demographics
NPI:1649629577
Name:GODWIN, MICHELE PATRICE (PHD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:PATRICE
Last Name:GODWIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4551 STRUTFIELD LN
Mailing Address - Street 2:APT. 4313
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-4967
Mailing Address - Country:US
Mailing Address - Phone:703-501-6101
Mailing Address - Fax:
Practice Address - Street 1:100 N PITT ST
Practice Address - Street 2:SUITE 320
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-3134
Practice Address - Country:US
Practice Address - Phone:703-249-5198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003579103TC0700X
DCPSY1000306103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical