Healthcare Provider Details

I. General information

NPI: 1477389443
Provider Name (Legal Business Name): DUSTIN GODWIN LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S WOODLAWN AVE STE 15
O FALLON MO
63366-7647
US

IV. Provider business mailing address

345 HIGHGROVE PLACE DR
O FALLON MO
63366-4384
US

V. Phone/Fax

Practice location:
  • Phone: 636-379-1779
  • Fax:
Mailing address:
  • Phone: 314-583-2705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2024033725
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: