Provider Demographics
NPI:1508412750
Name:GOODWINE, ALYSSA MARINA-NICOLE (NCC, LPCA)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARINA-NICOLE
Last Name:GOODWINE
Suffix:
Gender:F
Credentials:NCC, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 CLANTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 COPPERFIELD BLVD NE STE 105
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2429
Practice Address - Country:US
Practice Address - Phone:704-782-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15027101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional