Provider Demographics
NPI:1003389602
Name:GOINES, MICHELLE ANTOINETTE (LCSW-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANTOINETTE
Last Name:GOINES
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 N ELLAMONT ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-3817
Mailing Address - Country:US
Mailing Address - Phone:410-419-9823
Mailing Address - Fax:
Practice Address - Street 1:1522 N ELLAMONT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216
Practice Address - Country:US
Practice Address - Phone:410-419-9823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD234091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical