Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 25101 | TX |
Y | 103T00000X | Psychologist | 25101 | TX |
N | 103TA0700X | Adult Development & Aging Psychologist | 25101 | TX |
N | 103TB0200X | Cognitive & Behavioral Psychologist | 25101 | TX |
N | 103G00000X | Clinical Psychologist | 25101 | TX |
N | 103TC0700X | Clinical Psychologist | 25101 | TX |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | 25101 | TX |
N | 103TF0000X | Family Psychologist | 25101 | TX |
NPI | 1023029170 |
---|---|
Provider Name | Dr. John Phillip Godfrey |
First Address | Austin, TX 78715-2680 |
Second Address | Austin, TX 78731-5039 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/08/2006 |
Last Update Date | 04/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0003LJ | BCBS NUMBER (01) | TX |
040973202 | (05) | TX |
160306 | VALUE OPTIONS (01) | TX |
97034000 | MAGELLAN ID NUMBER (01) | TX |