Provider Demographics
NPI:1053045542
Name:GOULD, MADELINE RUTH (JD, MSW, LCSWA)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:RUTH
Last Name:GOULD
Suffix:
Gender:F
Credentials:JD, MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 SILENT MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6869
Mailing Address - Country:US
Mailing Address - Phone:704-641-1367
Mailing Address - Fax:
Practice Address - Street 1:640 SUMMIT CROSS PLACE
Practice Address - Street 2:SUITE 203
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054
Practice Address - Country:US
Practice Address - Phone:704-237-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005008272084P0802X
NCP0180551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry