Provider Demographics
NPI:1710720222
Name:GOODWIN, CLARICE EVANS
Entity type:Individual
Prefix:
First Name:CLARICE
Middle Name:EVANS
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 EUGENE SASSER
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-1422
Mailing Address - Country:US
Mailing Address - Phone:435-830-8600
Mailing Address - Fax:
Practice Address - Street 1:4372 N LOOP 1604 W STE 202
Practice Address - Street 2:
Practice Address - City:SHAVANO PARK
Practice Address - State:TX
Practice Address - Zip Code:78249-1201
Practice Address - Country:US
Practice Address - Phone:210-541-1447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205331106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist