Provider Demographics
NPI:1538399480
Name:GOODWIN, ELISABETH MEGAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:MEGAN
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1124
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94011-1124
Mailing Address - Country:US
Mailing Address - Phone:831-277-3852
Mailing Address - Fax:
Practice Address - Street 1:727 INDUSTRIAL RD STE 104
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-3390
Practice Address - Country:US
Practice Address - Phone:650-204-1370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-24
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAPSY 24453103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health