Provider Demographics
NPI:1003106279
Name:GOODWYN, SUSAN WINDHAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:WINDHAM
Last Name:GOODWYN
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 1:3358 MIX CANYON RD
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-9012
Mailing Address - Country:US
Mailing Address - Phone:707-455-8541
Mailing Address - Fax:707-455-7435
Practice Address - Street 1:301 ALAMO DR
Practice Address - Street 2:A1
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-4246
Practice Address - Country:US
Practice Address - Phone:707-455-8541
Practice Address - Fax:707-455-7435
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-08
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24190103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical