Basic Information
| Provider Information | |||||||||
| NPI: | 1992982458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NELSON | ||||||||
| OtherFirstName: | DEBORAH | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 710 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503988480 | ||||||||
| FaxNumber: | 8503988482 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503988480 | ||||||||
| FaxNumber: | 8503988482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2008 | ||||||||
| LastUpdateDate: | 01/28/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT6063 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.