Provider Demographics
NPI:1164793436
Name:GOODWIN, TERE P (LPC, NCC)
Entity Type:Individual
Prefix:MS
First Name:TERE
Middle Name:P
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 BASTILLE WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7652
Mailing Address - Country:US
Mailing Address - Phone:770-461-7010
Mailing Address - Fax:770-461-7100
Practice Address - Street 1:170 BASTILLE WAY
Practice Address - Street 2:SUITE C
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7652
Practice Address - Country:US
Practice Address - Phone:770-461-7010
Practice Address - Fax:770-461-7100
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004357101YP2500X
101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool