Provider Demographics
NPI:1760873004
Name:GOODWIN, GARY D (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:D
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 S 2ND ST W
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-5218
Mailing Address - Country:US
Mailing Address - Phone:928-243-8172
Mailing Address - Fax:
Practice Address - Street 1:440 S 2ND ST W
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5218
Practice Address - Country:US
Practice Address - Phone:928-243-8172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW 154441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical