Provider Demographics
NPI:1306998349
Name:GOODWIN, GERALD EVELYN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:GERALD
Middle Name:EVELYN
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:GERALD
Other - Middle Name:EVELYN
Other - Last Name:DEHAVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3531 SLADE RUN DR
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-3923
Mailing Address - Country:US
Mailing Address - Phone:703-237-2231
Mailing Address - Fax:703-237-2231
Practice Address - Street 1:3531 SLADE RUN DR
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3923
Practice Address - Country:US
Practice Address - Phone:703-237-2231
Practice Address - Fax:703-237-2231
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09043352101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8945616Medicaid
VA394133OtherUNITED MAMSI
VA7745413OtherAETNA
VAM607OtherCARE FIRST
VAM607OtherCARE FIRST
VA8945616Medicaid