Provider Demographics
NPI:1508095316
Name:GOODWIN, CARL LEWIS
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:LEWIS
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 1:10626 E ENID AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-7276
Mailing Address - Country:US
Mailing Address - Phone:602-384-5443
Mailing Address - Fax:480-981-5555
Practice Address - Street 1:10626 E ENID AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85208-7276
Practice Address - Country:US
Practice Address - Phone:602-384-5443
Practice Address - Fax:480-981-5555
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health