Provider Demographics
NPI:1932447950
Name:MICHAEL-RENEE GODFREY, RN, LPC, PC
Entity type:Organization
Organization Name:MICHAEL-RENEE GODFREY, RN, LPC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHAEL-RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:RN, LPC, DCC
Authorized Official - Phone:678-401-8106
Mailing Address - Street 1:2453 POWDER SPRINGS RD SW
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-4570
Mailing Address - Country:US
Mailing Address - Phone:678-401-8106
Mailing Address - Fax:678-398-9065
Practice Address - Street 1:2453 POWDER SPRINGS RD SW
Practice Address - Street 2:SUITE 320
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-4570
Practice Address - Country:US
Practice Address - Phone:678-401-8106
Practice Address - Fax:678-398-9065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6036101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA498827642BMedicaid