MEDICARE: MR. RUTHIE BEA GOODWIN

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	101YP2500X	Professional Counselor	12874	TX

General Provider Information

NPI Number	:	1386421451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RUTHIE BEA GOODWIN

Provider Business Mailing Address
First Line	:	4027 ISLAND CREEK RD
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31601-0191
Country	:	US
Telephone Number	:	817-629-6139
Fax Number	:

Provider Business Practice Location Address
First Line	:	4027 ISLAND CREEK RD
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31601-0191
Country	:	US
Telephone Number	:	817-629-6139
Fax Number	:

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

Provider Enumeration Date	:	09/12/2023
Last Update Date	:	09/12/2023

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Directions to “ MR. RUTHIE BEA GOODWIN ” Practice Location

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