Basic Information
| Provider Information | |||||||||
| NPI: | 1730650615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | DONNAL | ||||||||
| MiddleName: | BLAKE | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 GENEVA | ||||||||
| Address2: | |||||||||
| City: | CORRIGAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75939 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 W PARK | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773518151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9363285021 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2018 | ||||||||
| LastUpdateDate: | 12/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 221830 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 19091795 | 01 | TX | DRIVES LICENSE | OTHER | 209855 | 01 | TX | TBOTE CERTIFICATION | OTHER | 221830 | 01 | TX | NBCOT LICENSE | OTHER |