Provider Demographics
NPI:1033293386
Name:GOLSTON, CARLOS (CCC, SLP)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:GOLSTON
Suffix:
Gender:M
Credentials:CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4222 FAIRFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4222 FAIRFIELD CIR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3628
Practice Address - Country:US
Practice Address - Phone:706-831-4572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005797235Z00000X
SC3264235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0404Medicaid
GA341979OtherWELLCARE
GA10054102OtherAMERIGROUP