Provider Demographics
NPI:1538352869
Name:GOODWIN, BRANDY K (MALLP)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:K
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:MALLP
Other - Prefix:
Other - First Name:BRANDY
Other - Middle Name:K
Other - Last Name:GOODWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-0428
Mailing Address - Country:US
Mailing Address - Phone:989-723-0732
Mailing Address - Fax:
Practice Address - Street 1:2157 UNIVERSITY PARK DR
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-5956
Practice Address - Country:US
Practice Address - Phone:517-243-9738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012316103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist