Provider Demographics
NPI:1063832657
Name:GOULD, AMY L (BCABA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:GOULD
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 MADISON RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-1428
Mailing Address - Country:US
Mailing Address - Phone:513-861-0300
Mailing Address - Fax:513-861-0213
Practice Address - Street 1:4850 MADISON RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45227-1428
Practice Address - Country:US
Practice Address - Phone:513-861-0300
Practice Address - Fax:513-861-0213
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0-13-5573106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0500833Medicaid
OH0302563Medicaid