MEDICARE: MRS. ANGLE M GOLDSTON MS, QP, CPSS, LCAS-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	174400000X	Specialist	2013-1048-01	NC
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCASA-20069	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2013-1048-01	OTHER	NC	NORTH CAROLINA CERTIFIED PEER SUPPORT SPECIALIST
2	LCASA-20069	OTHER	NC	NC SUBSTANCE ABUSE PROFESSIONAL BOARD

General Provider Information

NPI Number	:	1952610560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANGLE M GOLDSTON MS, QP, CPSS, LCAS-A

Provider Business Mailing Address
First Line	:	5135 N CHURCH ST
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27455-1339
Country	:	US
Telephone Number	:	336-324-7761
Fax Number	:

Provider Business Practice Location Address
First Line	:	5135 N CHURCH ST
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27455-1339
Country	:	US
Telephone Number	:	336-324-7761
Fax Number	:

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

Provider Enumeration Date	:	09/29/2010
Last Update Date	:	06/16/2018

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