Provider Demographics
NPI:1376605915
Name:GOUDELOCK, WILLIAM MICHAEL (LPC LCAS)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:GOUDELOCK
Suffix:
Gender:M
Credentials:LPC LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013B WEST AVE NW
Mailing Address - Street 2:
Mailing Address - City:LENOIR
Mailing Address - State:NC
Mailing Address - Zip Code:28645-5126
Mailing Address - Country:US
Mailing Address - Phone:828-572-1636
Mailing Address - Fax:828-572-1637
Practice Address - Street 1:1013B WEST AVE NW
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-5126
Practice Address - Country:US
Practice Address - Phone:828-572-1636
Practice Address - Fax:828-572-1637
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC943101YA0400X
NC5495101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111785Medicaid