Provider Demographics
NPI:1588924401
Name:GOLSON, CHANTAY YOLANDA (LPC, CAMS)
Entity type:Individual
Prefix:
First Name:CHANTAY
Middle Name:YOLANDA
Last Name:GOLSON
Suffix:
Gender:F
Credentials:LPC, CAMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-6086
Mailing Address - Country:US
Mailing Address - Phone:770-280-7288
Mailing Address - Fax:770-983-6098
Practice Address - Street 1:3400 CHAPEL HILL RD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1739
Practice Address - Country:US
Practice Address - Phone:770-280-7288
Practice Address - Fax:770-983-6098
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007288101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003126621AMedicaid