Provider Demographics
NPI:1851837264
Name:GOODWILL, MICHELLE RENEE (MC, LAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:GOODWILL
Suffix:
Gender:F
Credentials:MC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 E WARNER RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3054
Mailing Address - Country:US
Mailing Address - Phone:480-444-2434
Mailing Address - Fax:
Practice Address - Street 1:2943 E AUSTIN DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-0594
Practice Address - Country:US
Practice Address - Phone:602-582-5124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC 16387101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health