Provider Demographics
NPI:1922696871
Name:GOODWIN, SUSAN E
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
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 1:1364 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WEST PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45663-6013
Mailing Address - Country:US
Mailing Address - Phone:740-352-0240
Mailing Address - Fax:
Practice Address - Street 1:1364 3RD ST
Practice Address - Street 2:
Practice Address - City:WEST PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45663-6013
Practice Address - Country:US
Practice Address - Phone:740-352-0240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRS348413172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver