1588924401 NPI number — CHANTAY YOLANDA GOLSON LPC, CAMS

Table of content: CHANTAY YOLANDA GOLSON LPC, CAMS (NPI 1588924401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588924401 NPI number — CHANTAY YOLANDA GOLSON LPC, CAMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLSON
Provider First Name:
CHANTAY
Provider Middle Name:
YOLANDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, CAMS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588924401
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1086
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VILLA RICA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30180-6086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-280-7288
Provider Business Mailing Address Fax Number:
770-983-6098

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 CHAPEL HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30135-1739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-280-7288
Provider Business Practice Location Address Fax Number:
770-983-6098
Provider Enumeration Date:
05/24/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  007288 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003126621A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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