Provider Demographics
NPI:1053499434
Name:GOULD, STACEY IRENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:IRENE
Last Name:GOULD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9075
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91372-9075
Mailing Address - Country:US
Mailing Address - Phone:818-679-9556
Mailing Address - Fax:
Practice Address - Street 1:21201 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91303-2830
Practice Address - Country:US
Practice Address - Phone:818-679-9556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18889103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical