Provider Demographics
NPI:1023563095
Name:GOODWIN, ASHLEY NIESHA (LCSWA)
Entity Type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:NIESHA
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13912 CEDAR FARM RD
Mailing Address - Street 2:APT 207
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-7532
Mailing Address - Country:US
Mailing Address - Phone:843-568-8419
Mailing Address - Fax:
Practice Address - Street 1:9711 DAVID TAYLOR DR APT 201
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-2370
Practice Address - Country:US
Practice Address - Phone:704-910-0136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2020-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0142031041C0700X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid
SC301100Medicaid