Provider Demographics
NPI:1982750352
Name:GOODWIN, EDITH SHUNK (PT)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:SHUNK
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-2438
Mailing Address - Country:US
Mailing Address - Phone:712-322-2903
Mailing Address - Fax:
Practice Address - Street 1:2600 S 9TH ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-7541
Practice Address - Country:US
Practice Address - Phone:712-322-7354
Practice Address - Fax:712-322-7419
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA009872251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics