Provider Demographics
NPI:1902964398
Name:GOODWIN, NICOLE (CASE MANAGER)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-5243
Mailing Address - Country:US
Mailing Address - Phone:805-458-9491
Mailing Address - Fax:805-221-6213
Practice Address - Street 1:784 HIGH ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-5243
Practice Address - Country:US
Practice Address - Phone:805-801-3017
Practice Address - Fax:805-221-6213
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT31294167G00000X
171M00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator