Provider Demographics
NPI:1659552651
Name:GOODEN, ANTOINETTE (LPC, NCC, MAC, ACS)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:GOODEN
Suffix:
Gender:F
Credentials:LPC, NCC, MAC, ACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6777
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30154-0030
Mailing Address - Country:US
Mailing Address - Phone:404-692-1014
Mailing Address - Fax:404-393-1868
Practice Address - Street 1:6000 STEWART PARKWAY
Practice Address - Street 2:#6777
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-6777
Practice Address - Country:US
Practice Address - Phone:404-692-1014
Practice Address - Fax:404-393-1868
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-18
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAMAC 508018101YA0400X
NCNCC 236587101YM0800X
GASRS P12 683283101YS0200X
5080183245S0500X
GALPC005074101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children