Provider Demographics
NPI:1851146237
Name:GOODWIN, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 7TH ST FL 3
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-1486
Mailing Address - Country:US
Mailing Address - Phone:706-842-5330
Mailing Address - Fax:706-842-5340
Practice Address - Street 1:2849 HENDERSON MILL RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-5772
Practice Address - Country:US
Practice Address - Phone:706-842-5330
Practice Address - Fax:706-842-5340
Is Sole Proprietor?:No
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-24-342179106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician