1922579481 NPI number — MRS. KRISTY TERESA GODWIN LGPC

Table of content: MRS. KRISTY TERESA GODWIN LGPC (NPI 1922579481)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922579481 NPI number — MRS. KRISTY TERESA GODWIN LGPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GODWIN
Provider First Name:
KRISTY
Provider Middle Name:
TERESA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LGPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922579481
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/23/2019
NPI Reactivation Date:
07/12/2024

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13603 MARY BOWIE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UPPER MARLBORO
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20774-9075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-651-4019
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3242 ESTHER PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21224-1431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-898-8282
Provider Business Practice Location Address Fax Number:
443-898-8130
Provider Enumeration Date:
12/10/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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