Provider Demographics
NPI:1659962652
Name:GODINEZ, BLANCA
Entity type:Individual
Prefix:
First Name:BLANCA
Middle Name:
Last Name:GODINEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25765 ECHO VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HOMELAND
Mailing Address - State:CA
Mailing Address - Zip Code:92548-9619
Mailing Address - Country:US
Mailing Address - Phone:951-293-9455
Mailing Address - Fax:
Practice Address - Street 1:790 S STATE ST STE 6
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4924
Practice Address - Country:US
Practice Address - Phone:951-654-6002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1571920724101YA0400X
1266241041C0700X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical