Provider Demographics
NPI:1063757037
Name:GOODWIN, MICHAELINA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICHAELINA
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 E PASTURE CANYON DR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5813
Mailing Address - Country:US
Mailing Address - Phone:970-560-0123
Mailing Address - Fax:
Practice Address - Street 1:464 E PASTURE CANYON DR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-5813
Practice Address - Country:US
Practice Address - Phone:970-560-0123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP-8002235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist