Provider Demographics
NPI:1770792624
Name:GODBOUT, ROBERT MAURICE (MHC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MAURICE
Last Name:GODBOUT
Suffix:
Gender:M
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8821 RT 90
Mailing Address - Street 2:
Mailing Address - City:KING FERRY
Mailing Address - State:NY
Mailing Address - Zip Code:13081
Mailing Address - Country:US
Mailing Address - Phone:315-364-7235
Mailing Address - Fax:
Practice Address - Street 1:8821 RT 90
Practice Address - Street 2:
Practice Address - City:KING FERRY
Practice Address - State:NY
Practice Address - Zip Code:13081
Practice Address - Country:US
Practice Address - Phone:315-364-7235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002102101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY002102OtherMENTAL HEALTH COUNSELOR