Provider Demographics
NPI:1124708284
Name:GOLDSMITH, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:GOLDSMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 IVY STONE DR
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-7761
Mailing Address - Country:US
Mailing Address - Phone:336-880-2779
Mailing Address - Fax:
Practice Address - Street 1:3625 N ELM ST STE 130
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2604
Practice Address - Country:US
Practice Address - Phone:704-360-3637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17632101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty