Healthcare Provider Details

I. General information

NPI: 1972924348
Provider Name (Legal Business Name): JIMMY M GODWIN LCSWA, LCASA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2014
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 DAMASCUS RD
FAYETTEVILLE NC
28303-4662
US

IV. Provider business mailing address

2929 DAMASCUS RD
FAYETTEVILLE NC
28303-4662
US

V. Phone/Fax

Practice location:
  • Phone: 910-229-2468
  • Fax: 910-229-2868
Mailing address:
  • Phone: 910-229-2468
  • Fax: 910-229-2868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP007656
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3304-A
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: