Provider Demographics
NPI:1407103724
Name:GOODWIN, SAMANTHA (LMSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 S LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1836
Mailing Address - Country:US
Mailing Address - Phone:517-526-5379
Mailing Address - Fax:
Practice Address - Street 1:332 S LINCOLN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-1836
Practice Address - Country:US
Practice Address - Phone:517-526-5379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801093532104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker