MEDICARE: CASSI LYNNETTE GOFORTH LMFT-A

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	106H00000X	Marriage & Family Therapist	7077A	NC
2	106H00000X	Marriage & Family Therapist	1485	NC

General Provider Information

NPI Number	:	1376815720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASSI LYNNETTE GOFORTH LMFT-A

Provider Business Mailing Address
First Line	:	13331 BINNAWAY RD
Second Line	:
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-9327
Country	:	US
Telephone Number	:	704-650-5384
Fax Number	:

Provider Business Practice Location Address
First Line	:	5925 CARNEGIE BLVD
Second Line	:	SUITE 350
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-4655
Country	:	US
Telephone Number	:	704-660-6854
Fax Number	:

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

Provider Enumeration Date	:	02/01/2012
Last Update Date	:	08/02/2013

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