Healthcare Provider Details

I. General information

NPI: 1659552651
Provider Name (Legal Business Name): ANTOINETTE GOODEN LPC, NCC, MAC, ACS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2007
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 STEWART PARKWAY #6777
DOUGLASVILLE GA
30135-6777
US

IV. Provider business mailing address

PO BOX 6777
DOUGLASVILLE GA
30154-0030
US

V. Phone/Fax

Practice location:
  • Phone: 404-692-1014
  • Fax: 404-393-1868
Mailing address:
  • Phone: 404-692-1014
  • Fax: 404-393-1868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMAC 508018
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberNCC 236587
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberSRS P12 683283
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number508018
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC005074
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: