Provider Demographics
NPI:1235350562
Name:GOOLSBY, KEVIN (MA, LMHC, NCC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:GOOLSBY
Suffix:
Gender:M
Credentials:MA, LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9233 REDTAIL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32222-2811
Mailing Address - Country:US
Mailing Address - Phone:904-338-2998
Mailing Address - Fax:
Practice Address - Street 1:2720 PARK STREET STE 202
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32222-3810
Practice Address - Country:US
Practice Address - Phone:904-338-2998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMH12309101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL768184400Medicaid