Provider Demographics
NPI:1902354178
Name:GOODWIN, MIRANDA (LCSW)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SATSUMA
Mailing Address - State:AL
Mailing Address - Zip Code:36572-2204
Mailing Address - Country:US
Mailing Address - Phone:205-792-7035
Mailing Address - Fax:
Practice Address - Street 1:3737 GOVERNMENT BLVD STE 203
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-4310
Practice Address - Country:US
Practice Address - Phone:251-300-7134
Practice Address - Fax:251-202-7851
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3761C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical