Provider Demographics
NPI:1720619679
Name:GOODWIN, JOHN WESLEY III (LPCA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WESLEY
Last Name:GOODWIN
Suffix:III
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5015 STOWE DERBY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-7377
Mailing Address - Country:US
Mailing Address - Phone:704-701-4463
Mailing Address - Fax:
Practice Address - Street 1:5015 STOWE DERBY DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-7377
Practice Address - Country:US
Practice Address - Phone:704-701-4463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15374101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional