Provider Demographics
NPI:1053701383
Name:GOODWIN, DEANNA (CMT)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7938 COOLEY LAKE RD
Mailing Address - Street 2:SUITE 400W
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-4404
Mailing Address - Country:US
Mailing Address - Phone:248-345-6475
Mailing Address - Fax:
Practice Address - Street 1:7938 COOLEY LAKE RD
Practice Address - Street 2:SUITE 400W
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-4404
Practice Address - Country:US
Practice Address - Phone:248-345-6475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000594225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist