Provider Demographics
NPI:1528546710
Name:GOODWIN, CHARLES ALEXANDER (PT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALEXANDER
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 PARK HILL DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-3377
Mailing Address - Country:US
Mailing Address - Phone:540-412-7019
Mailing Address - Fax:
Practice Address - Street 1:501 PARK HILL DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3377
Practice Address - Country:US
Practice Address - Phone:540-412-7019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211887225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist