Provider Demographics
NPI:1558485458
Name:GOINES, WILLIE (ED S)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:GOINES
Suffix:
Gender:M
Credentials:ED S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BIG LEAF CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-9414
Mailing Address - Country:US
Mailing Address - Phone:803-788-7485
Mailing Address - Fax:
Practice Address - Street 1:2712 MIDDLEBURG DR STE 206
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2415
Practice Address - Country:US
Practice Address - Phone:803-779-0354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4799101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional