Provider Demographics
NPI:1013053610
Name:GOELLER, CYNTHIA K (LCPC)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:K
Last Name:GOELLER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 E CAYUGA ST
Mailing Address - Street 2:
Mailing Address - City:MORAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13118-9302
Mailing Address - Country:US
Mailing Address - Phone:434-900-5886
Mailing Address - Fax:
Practice Address - Street 1:1707 ROSEMOUNT AVE
Practice Address - Street 2:
Practice Address - City:FREDRICK
Practice Address - State:MD
Practice Address - Zip Code:21702
Practice Address - Country:US
Practice Address - Phone:443-900-5886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC-3565101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402989501OtherMEDICAID PRP
MD521450501Medicaid
MD402989500OtherMEDICAID PRP
MD521450500Medicaid
MD402989500OtherMEDICAID PRP
MD521450500Medicaid