Provider Demographics
NPI:1194053256
Name:GOODWIN, STEPHANIE ELAINE (MA, CSAC, QMHP)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:ELAINE
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:MA, CSAC, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 PIPIT DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-2978
Mailing Address - Country:US
Mailing Address - Phone:703-609-3338
Mailing Address - Fax:540-654-5859
Practice Address - Street 1:915 LAFAYETTE BLVD # C
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5667
Practice Address - Country:US
Practice Address - Phone:540-654-5113
Practice Address - Fax:540-654-5859
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710001130101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor