Provider Demographics
NPI:1720419872
Name:GOOLSBY, COURTNEY NICOLE
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:GOOLSBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:NICOLE
Other - Last Name:GOOLSBY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:310 WILDLIFE TRCE
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-7014
Mailing Address - Country:US
Mailing Address - Phone:904-449-6185
Mailing Address - Fax:
Practice Address - Street 1:5268 GODWIN BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8114
Practice Address - Country:US
Practice Address - Phone:757-255-7117
Practice Address - Fax:757-255-7139
Is Sole Proprietor?:No
Enumeration Date:2013-11-27
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007081101YP2500X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist