Healthcare Provider Details

I. General information

NPI: 1902964398
Provider Name (Legal Business Name): NICOLE GOODWIN SOCIAL WORKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 HIGH ST
SAN LUIS OBISPO CA
93401-5243
US

IV. Provider business mailing address

784 HIGH ST
SAN LUIS OBISPO CA
93401-5243
US

V. Phone/Fax

Practice location:
  • Phone: 805-540-6500
  • Fax:
Mailing address:
  • Phone: 805-540-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT31294
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: