Provider Demographics
NPI:1417483413
Name:GOODWIN, MEKELL
Entity Type:Individual
Prefix:
First Name:MEKELL
Middle Name:
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 1:430 MARSHALL WALK
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-2632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:804 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1224
Practice Address - Country:US
Practice Address - Phone:859-254-1035
Practice Address - Fax:859-254-2075
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker