Provider Demographics
NPI:1861972929
Name:GOODWIN, BRIDGET SHAYANN
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:SHAYANN
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 1:2001 HOLLEY PKWY APT 413
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-4451
Mailing Address - Country:US
Mailing Address - Phone:806-240-0975
Mailing Address - Fax:
Practice Address - Street 1:4101 LONG PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1567
Practice Address - Country:US
Practice Address - Phone:214-285-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212767224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant