MEDICARE: WILLIAM MICHAEL GOUDELOCK LPC LCAS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	943	NC
2	101YM0800X	Mental Health Counselor	5495	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376605915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM MICHAEL GOUDELOCK LPC LCAS

Provider Business Mailing Address
First Line	:	1013B WEST AVE NW
Second Line	:
City	:	LENOIR
State	:	NC
Zip	:	28645-5126
Country	:	US
Telephone Number	:	828-572-1636
Fax Number	:	828-572-1637

Provider Business Practice Location Address
First Line	:	1013B WEST AVE NW
Second Line	:
City	:	LENOIR
State	:	NC
Zip	:	28645-5126
Country	:	US
Telephone Number	:	828-572-1636
Fax Number	:	828-572-1637

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

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	10/22/2008

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