Healthcare Provider Details

I. General information

NPI: 1003491564
Provider Name (Legal Business Name): NICOLE SONNLEITNER GOODE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409A URBANA PIKE STE 2A
FREDERICK MD
21704-7794
US

IV. Provider business mailing address

5480 WISCONSIN AVE STE 201
CHEVY CHASE MD
20815-3524
US

V. Phone/Fax

Practice location:
  • Phone: 443-788-4266
  • Fax:
Mailing address:
  • Phone: 588-830-1852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC13400
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP11227
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: