Provider Demographics
NPI:1013274075
Name:GOODWIN, ALYSSON MILLER (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:ALYSSON
Middle Name:MILLER
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:ALYSSON
Other - Middle Name:MAVIS
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:29 RACE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-4634
Mailing Address - Country:US
Mailing Address - Phone:318-792-1696
Mailing Address - Fax:
Practice Address - Street 1:29 RACE ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-4634
Practice Address - Country:US
Practice Address - Phone:318-792-1696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3904225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist