Provider Demographics
NPI:1194491480
Name:GOODWIN, DAZIALEE (PHD)
Entity type:Individual
Prefix:
First Name:DAZIALEE
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3627 MCREE AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2617
Mailing Address - Country:US
Mailing Address - Phone:618-719-3838
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS PL STE 3N-14
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent