Provider Demographics
NPI:1154184836
Name:SOAT, GWEN (LCMHCA)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:SOAT
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 SIX FORKS RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-4462
Mailing Address - Country:US
Mailing Address - Phone:919-886-4052
Mailing Address - Fax:919-886-4052
Practice Address - Street 1:5401 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4462
Practice Address - Country:US
Practice Address - Phone:919-886-4052
Practice Address - Fax:919-886-4052
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19679101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health