MEDICARE: MISTY GOODWIN LPES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	4580	SC

General Provider Information

NPI Number	:	1356787865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY GOODWIN LPES

Provider Business Mailing Address
First Line	:	1311 CHANDLER CIR
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29505-6467
Country	:	US
Telephone Number	:	843-468-1850
Fax Number	:

Provider Business Practice Location Address
First Line	:	1311 CHANDLER CIR
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29505-6467
Country	:	US
Telephone Number	:	843-468-1850
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2013
Last Update Date	:	05/13/2013

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Directions to “ MISTY GOODWIN LPES” Practice Location

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