Provider Demographics
NPI:1922579481
Name:GODWIN, KRISTY TERESA (LGPC)
Entity type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:TERESA
Last Name:GODWIN
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13603 MARY BOWIE PKWY
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-9075
Mailing Address - Country:US
Mailing Address - Phone:443-651-4019
Mailing Address - Fax:
Practice Address - Street 1:3242 ESTHER PL
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-1431
Practice Address - Country:US
Practice Address - Phone:443-898-8282
Practice Address - Fax:443-898-8130
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2024-07-12
Deactivation Date:2019-05-23
Deactivation Code:
Reactivation Date:2024-07-12
Provider Licenses
StateLicense IDTaxonomies
MD101YM0800X, 103TB0200X, 103TC1900X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD46-5228785Medicaid