Provider Demographics
NPI:1144410614
Name:GOODWIN, DIANA (SLP)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7029 INDIAN WELLS RD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-2520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 N ACADEMY ST
Practice Address - Street 2:253
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-4540
Practice Address - Country:US
Practice Address - Phone:919-467-3692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1548235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC36189OtherBCBSNC
NC7436189Medicaid