Provider Demographics
NPI:1396709051
Name:GOODWIN, COLLEEN A (OT)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:A
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3441 STEMBLER RDG
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-7609
Mailing Address - Country:US
Mailing Address - Phone:770-920-0574
Mailing Address - Fax:770-920-0574
Practice Address - Street 1:3441 STEMBLER RDG
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7609
Practice Address - Country:US
Practice Address - Phone:770-920-0574
Practice Address - Fax:770-920-0574
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT001102225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA67BBBGVMedicare ID - Type Unspecified
GAS41838Medicare UPIN