Provider Demographics
NPI:1528260676
Name:GODWIN, TIFFANY NICOLE (PHD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:GODWIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15411 W WADDELL RD STE 102-1073
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-5170
Mailing Address - Country:US
Mailing Address - Phone:850-739-2332
Mailing Address - Fax:623-632-0097
Practice Address - Street 1:15411 W WADDELL RD STE 102-1073
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-5170
Practice Address - Country:US
Practice Address - Phone:850-739-2332
Practice Address - Fax:623-632-0097
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPSY005014103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health