Provider Demographics
NPI:1902964398
Name:GOODWIN, NICOLE (SOCIAL WORKER)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 KENDALL RD
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-8750
Mailing Address - Country:US
Mailing Address - Phone:805-534-3040
Mailing Address - Fax:
Practice Address - Street 1:1255 KENDALL RD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-8750
Practice Address - Country:US
Practice Address - Phone:805-534-3040
Practice Address - Fax:805-221-6213
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT31294167G00000X, 373H00000X
225400000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No172V00000XOther Service ProvidersCommunity Health Worker