Basic Information
| Provider Information | |||||||||
| NPI: | 1801951785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOOLSBY | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | CPS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1510 SUGARPLUM PL SW | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300946844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709186677 | ||||||||
| FaxNumber: | 7709186686 | ||||||||
| Practice Location | |||||||||
| Address1: | 977 TAYLOR ST SW | ||||||||
| Address2: | SUITE-A | ||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300125357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709186677 | ||||||||
| FaxNumber: | 7709186686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.