Provider Demographics
NPI:1245621507
Name:GOODWIN, KIMBERLY LYNN (BSN, MRC, CRC, LPC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:BSN, MRC, CRC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25490 LITTLE MACK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-2157
Mailing Address - Country:US
Mailing Address - Phone:586-246-7837
Mailing Address - Fax:
Practice Address - Street 1:25490 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2157
Practice Address - Country:US
Practice Address - Phone:586-246-7837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010236101YP2500X
MI4704247001163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No163WR0400XNursing Service ProvidersRegistered NurseRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
11861990OtherCAQH