Provider Demographics
NPI:1801236484
Name:GOODMAN, ANNETTE (LCAS-A)
Entity type:Individual
Prefix:MISS
First Name:ANNETTE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7729 PETREA LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-1061
Mailing Address - Country:US
Mailing Address - Phone:704-491-4011
Mailing Address - Fax:
Practice Address - Street 1:415 E. TRADE STREET
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202
Practice Address - Country:US
Practice Address - Phone:704-377-5047
Practice Address - Fax:704-377-5043
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3206-A101YA0400X, 225C00000X
NC3201-A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor