Provider Demographics
NPI:1780343657
Name:GOODWIN, DAVINA RUTH
Entity type:Individual
Prefix:
First Name:DAVINA
Middle Name:RUTH
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 1:588 W GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:OH
Mailing Address - Zip Code:44146-3203
Mailing Address - Country:US
Mailing Address - Phone:216-551-2385
Mailing Address - Fax:
Practice Address - Street 1:588 W GLENDALE ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:OH
Practice Address - Zip Code:44146-3203
Practice Address - Country:US
Practice Address - Phone:216-551-2385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 175T00000X
OH1780343657175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)