Provider Demographics
NPI:1912603663
Name:GODBOUT, ELVIA
Entity type:Individual
Prefix:
First Name:ELVIA
Middle Name:
Last Name:GODBOUT
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 1:45 E NEWTON ST # JC309
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4802
Mailing Address - Country:US
Mailing Address - Phone:607-262-2136
Mailing Address - Fax:
Practice Address - Street 1:45 E NEWTON ST # JC309
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4802
Practice Address - Country:US
Practice Address - Phone:607-262-2136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool