Healthcare Provider Details

I. General information

NPI: 1053920090
Provider Name (Legal Business Name): DACOTA GOODWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 WHEELER RD SE
WASHINGTON DC
20032-4129
US

IV. Provider business mailing address

6319 WALDEN AVE
CHATTANOOGA TN
37421-2329
US

V. Phone/Fax

Practice location:
  • Phone: 312-965-2997
  • Fax:
Mailing address:
  • Phone: 423-227-3861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number200001698
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: