Provider Demographics
NPI:1629264346
Name:GOODWINE, IDA BLAN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:IDA
Middle Name:BLAN
Last Name:GOODWINE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:IDA
Other - Middle Name:
Other - Last Name:FREEMAN GOODWINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:220 BEACH 87TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11693-1604
Mailing Address - Country:US
Mailing Address - Phone:718-318-6536
Mailing Address - Fax:718-318-6597
Practice Address - Street 1:220 BEACH 87TH ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1604
Practice Address - Country:US
Practice Address - Phone:718-318-6536
Practice Address - Fax:718-318-6597
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-16
Last Update Date:2007-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028031-1104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical