Provider Demographics
NPI:1558431932
Name:GOODWIN, CRAIG M (PT)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:M
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 1:3921 WILLIAMS BLVD
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065
Mailing Address - Country:US
Mailing Address - Phone:504-443-5152
Mailing Address - Fax:504-443-5151
Practice Address - Street 1:3921 WILLIAMS BLVD
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065
Practice Address - Country:US
Practice Address - Phone:504-443-5152
Practice Address - Fax:504-443-5151
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT 00749225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA55662CK91Medicare ID - Type Unspecified