Provider Demographics
NPI:1215316120
Name:GODOY, CARLOS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:GODOY
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:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC
Mailing Address - Street 2:994 S HARRISON RD
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85748
Mailing Address - Country:US
Mailing Address - Phone:520-721-1887
Mailing Address - Fax:
Practice Address - Street 1:6108 E BRAMBLE ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85756
Practice Address - Country:US
Practice Address - Phone:520-437-2437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6954828171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor