Provider Demographics
NPI:1306112818
Name:GOODMAN, KARENSA (NCC, LAPC)
Entity type:Individual
Prefix:
First Name:KARENSA
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:NCC, LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 ROLAND RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-5336
Mailing Address - Country:US
Mailing Address - Phone:706-253-1112
Mailing Address - Fax:706-253-1120
Practice Address - Street 1:323 ROLAND RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-5336
Practice Address - Country:US
Practice Address - Phone:706-253-1112
Practice Address - Fax:706-253-1120
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC003171101Y00000X
GALPC008080101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor