Provider Demographics
NPI:1255547949
Name:GOODMAN, KASSI LYNN (LPC)
Entity type:Individual
Prefix:
First Name:KASSI
Middle Name:LYNN
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 SAINT JAMES AVE
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-2836
Mailing Address - Country:US
Mailing Address - Phone:814-592-6609
Mailing Address - Fax:
Practice Address - Street 1:775 SAINT JAMES AVE
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-2836
Practice Address - Country:US
Practice Address - Phone:843-801-8011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid