Provider Demographics
NPI:1326537333
Name:GOLEY, SAMANTHA SUE GINGERICH (MS, LPC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:SUE GINGERICH
Last Name:GOLEY
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-8005
Mailing Address - Country:US
Mailing Address - Phone:937-550-9129
Mailing Address - Fax:937-790-1124
Practice Address - Street 1:325 N MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-8005
Practice Address - Country:US
Practice Address - Phone:937-550-9129
Practice Address - Fax:937-790-1124
Is Sole Proprietor?:No
Enumeration Date:2018-05-04
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1901636101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0332566Medicaid
OH0307150Medicaid