Provider Demographics
NPI:1679258925
Name:GOLDSON, LANCE RUEBEN JR
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:RUEBEN
Last Name:GOLDSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 LAKE CLUB DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-3204
Mailing Address - Country:US
Mailing Address - Phone:614-704-5224
Mailing Address - Fax:614-515-2693
Practice Address - Street 1:2211 LAKE CLUB DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-3204
Practice Address - Country:US
Practice Address - Phone:614-704-5224
Practice Address - Fax:614-515-2693
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health