Provider Demographics
NPI:1295438984
Name:GOODSON, DESTINY ROSE (CSAC SUPERVISEE)
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:ROSE
Last Name:GOODSON
Suffix:
Gender:F
Credentials:CSAC SUPERVISEE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 SLATE CREEK RD STE 201
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-6975
Mailing Address - Country:US
Mailing Address - Phone:276-242-2001
Mailing Address - Fax:
Practice Address - Street 1:1520 SLATE CREEK RD STE 201
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6975
Practice Address - Country:US
Practice Address - Phone:276-242-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0709025109101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)