Provider Demographics
NPI:1093309429
Name:KIMBERLY GOODWIN LCSW-S PLLC
Entity Type:Organization
Organization Name:KIMBERLY GOODWIN LCSW-S PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:SANDRA-LYNN
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-S
Authorized Official - Phone:210-857-3096
Mailing Address - Street 1:12119 CHERRY BLOSSOM ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-4311
Mailing Address - Country:US
Mailing Address - Phone:210-857-3096
Mailing Address - Fax:
Practice Address - Street 1:12119 CHERRY BLOSSOM ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-4311
Practice Address - Country:US
Practice Address - Phone:210-857-3096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX378227803Medicaid