Provider Demographics
NPI:1730650615
Name:GOODWIN, DONNAL BLAKE (COTA)
Entity Type:Individual
Prefix:
First Name:DONNAL
Middle Name:BLAKE
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GENEVA
Mailing Address - Street 2:
Mailing Address - City:CORRIGAN
Mailing Address - State:TX
Mailing Address - Zip Code:75939
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 W PARK
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-8151
Practice Address - Country:US
Practice Address - Phone:936-328-5021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221830224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX19091795OtherDRIVES LICENSE
TX209855OtherTBOTE CERTIFICATION
TX221830OtherNBCOT LICENSE