Provider Demographics
NPI:1902191950
Name:GOODWIN, GREGORY LEE
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:LEE
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2153 E JOYCE BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4714
Mailing Address - Country:US
Mailing Address - Phone:479-575-9771
Mailing Address - Fax:
Practice Address - Street 1:2153 E JOYCE BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4714
Practice Address - Country:US
Practice Address - Phone:479-575-9771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor