Provider Demographics
NPI:1730392341
Name:GOODWINE, VIOLET M (MSW)
Entity type:Individual
Prefix:
First Name:VIOLET
Middle Name:M
Last Name:GOODWINE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-2634
Mailing Address - Country:US
Mailing Address - Phone:307-864-3138
Mailing Address - Fax:307-864-3139
Practice Address - Street 1:121 S 4TH ST
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-2634
Practice Address - Country:US
Practice Address - Phone:307-864-3138
Practice Address - Fax:307-864-3139
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC # 1781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY108969204Medicaid
WY132369500Medicaid
WY108969205Medicaid