Provider Demographics
NPI:1649313982
Name:GOODWIN, AMANDA HOUSTON (LCSW)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:HOUSTON
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:LCSW
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:501 BILLINGSLEY ROAD
Mailing Address - Street 2:BEHAVIORAL HEALTH CENTER CMC RANDOLPH
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1009
Mailing Address - Country:US
Mailing Address - Phone:704-358-2710
Mailing Address - Fax:704-358-2938
Practice Address - Street 1:501 BILLINGSLEY ROAD
Practice Address - Street 2:BEHAVIORAL HEALTH CENTER CMC RANDOLPH
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1009
Practice Address - Country:US
Practice Address - Phone:704-358-2700
Practice Address - Fax:704-358-2716
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NCC0049481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1439FOtherBLUE CROSS BLUE SHIELD
NC6003780Medicaid