Provider Demographics
NPI:1508105289
Name:GOAD, DECEMBER L (LPC)
Entity type:Individual
Prefix:
First Name:DECEMBER
Middle Name:L
Last Name:GOAD
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 1:4217 ACCOMACK DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1829
Mailing Address - Country:US
Mailing Address - Phone:914-417-5787
Mailing Address - Fax:855-951-0188
Practice Address - Street 1:50 AL HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-6001
Practice Address - Country:US
Practice Address - Phone:912-417-5787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
KY102156101YM0800X
GALPC009595101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100298630Medicaid