Provider Demographics
NPI:1316484629
Name:GODWIN, LILA
Entity type:Individual
Prefix:
First Name:LILA
Middle Name:
Last Name:GODWIN
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 1:4610 N ARMENIA AVE
Mailing Address - Street 2:APT 321
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2735
Mailing Address - Country:US
Mailing Address - Phone:813-816-4238
Mailing Address - Fax:
Practice Address - Street 1:4610 N ARMENIA AVE
Practice Address - Street 2:APT 321
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2735
Practice Address - Country:US
Practice Address - Phone:813-816-4238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL656409Medicaid