Provider Demographics
NPI:1770071490
Name:GODINA, RUBY A
Entity type:Individual
Prefix:
First Name:RUBY
Middle Name:A
Last Name:GODINA
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 1:1316 WALL ST STE 2D
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3942
Mailing Address - Country:US
Mailing Address - Phone:425-340-3500
Mailing Address - Fax:425-287-6398
Practice Address - Street 1:1316 WALL ST STE 2D
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3942
Practice Address - Country:US
Practice Address - Phone:425-340-3500
Practice Address - Fax:425-287-6398
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW60713138104100000X, 1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2099350Medicaid