Provider Demographics
NPI:1225417454
Name:GODWIN, RUSSELL (LCSW)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:GODWIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:RUSSELL
Other - Middle Name:
Other - Last Name:GODWIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2784 N DECATUR RD STE 145
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5903
Mailing Address - Country:US
Mailing Address - Phone:404-234-6907
Mailing Address - Fax:404-292-2835
Practice Address - Street 1:2784 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5903
Practice Address - Country:US
Practice Address - Phone:404-234-6907
Practice Address - Fax:404-292-2835
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0024031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003181980AMedicaid