Healthcare Provider Details

I. General information

NPI: 1346384013
Provider Name (Legal Business Name): GLENN T GOODWIN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 DAYTON ST SUITE E
EDMONDS WA
98020-3601
US

IV. Provider business mailing address

555 DAYTON ST SUITE E
EDMONDS WA
98020-3601
US

V. Phone/Fax

Practice location:
  • Phone: 206-663-0816
  • Fax: 425-672-8655
Mailing address:
  • Phone: 206-663-0816
  • Fax: 425-672-8655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY00001999
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: