Provider Demographics
NPI:1346807310
Name:GOODWIN, WILLIAM THOMAS
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:THOMAS
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 DOGWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2005
Mailing Address - Country:US
Mailing Address - Phone:678-274-2805
Mailing Address - Fax:
Practice Address - Street 1:2750 OLD ALABAMA RD STE 200
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022
Practice Address - Country:US
Practice Address - Phone:678-893-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-24
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GAAPC007814101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program