Provider Demographics
NPI:1528296316
Name:GOODWIN, HARLEY LEE (HIS)
Entity type:Individual
Prefix:MR
First Name:HARLEY
Middle Name:LEE
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 E SUNSHINE
Mailing Address - Street 2:STE B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-812-7576
Mailing Address - Fax:417-812-7576
Practice Address - Street 1:1936 E SUNSHINE ST
Practice Address - Street 2:STE B
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1528
Practice Address - Country:US
Practice Address - Phone:417-812-7576
Practice Address - Fax:417-812-7576
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008028706237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist