Provider Demographics
NPI:1649576612
Name:DAVIS GOODWINE, DARLENE (LP, LCADC, CAADC)
Entity Type:Individual
Prefix:DR
First Name:DARLENE
Middle Name:
Last Name:DAVIS GOODWINE
Suffix:
Gender:F
Credentials:LP, LCADC, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 BURLINGTON LN STE 5
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-8444
Mailing Address - Country:US
Mailing Address - Phone:502-276-5096
Mailing Address - Fax:
Practice Address - Street 1:4710 W SAGINAW HWY STE 9
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-2654
Practice Address - Country:US
Practice Address - Phone:517-305-0641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018149103T00000X, 103TC0700X
KY276214101YA0400X
KY1135101YA0400X
MIC-03369101YA0400X
OHP.08296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100816960Medicaid