Provider Demographics
NPI:1952900060
Name:GODISAN, MIKAEL JOSEPH AURO
Entity Type:Individual
Prefix:
First Name:MIKAEL JOSEPH
Middle Name:AURO
Last Name:GODISAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16537 GARNET WAY
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-4926
Mailing Address - Country:US
Mailing Address - Phone:909-696-1180
Mailing Address - Fax:
Practice Address - Street 1:12235 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-3939
Practice Address - Country:US
Practice Address - Phone:714-202-0118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician