Provider Demographics
NPI:1407502602
Name:GOODWIN, SAMANTHA KAYE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KAYE
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S MAIN CROSS ST
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-1065
Mailing Address - Country:US
Mailing Address - Phone:606-638-0938
Mailing Address - Fax:
Practice Address - Street 1:125 S MAIN CROSS ST
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1065
Practice Address - Country:US
Practice Address - Phone:606-638-0938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2545261041C0700X
KY2576881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical