Basic Information
| Provider Information | |||||||||
| NPI: | 1578728325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | VENUS | ||||||||
| MiddleName: | SHERRILL | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | NONE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1143 MISSOURI ST | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945336007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074359911 | ||||||||
| FaxNumber: | 7074350704 | ||||||||
| Practice Location | |||||||||
| Address1: | 1143 MISSOURI ST | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945336007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074359911 | ||||||||
| FaxNumber: | 7074350704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2008 | ||||||||
| LastUpdateDate: | 07/22/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 01-047071 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.