Provider Demographics
NPI:1306131651
Name:GODIN, ERICA L
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:L
Last Name:GODIN
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 1:33 MEDWAY RD
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3220
Mailing Address - Country:US
Mailing Address - Phone:203-808-1966
Mailing Address - Fax:
Practice Address - Street 1:22 TOMPKINS ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-1459
Practice Address - Country:US
Practice Address - Phone:203-419-0381
Practice Address - Fax:203-419-0389
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1209224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004190328Medicaid
CT004190328Medicaid