Provider Demographics
NPI:1114115540
Name:ELIZABETH GOULD, MARRIAGE & FAMILY THERAPIST, INC.
Entity Type:Organization
Organization Name:ELIZABETH GOULD, MARRIAGE & FAMILY THERAPIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MFT
Authorized Official - Phone:310-578-5957
Mailing Address - Street 1:4170 ADMIRALTY WAY
Mailing Address - Street 2:SUITE 405
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-4618
Mailing Address - Country:US
Mailing Address - Phone:310-578-5957
Mailing Address - Fax:310-827-2294
Practice Address - Street 1:4170 ADMIRALTY WAY
Practice Address - Street 2:SUITE 405
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-4618
Practice Address - Country:US
Practice Address - Phone:310-578-5957
Practice Address - Fax:310-827-2294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC32388106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1306902754OtherINDIVIDUAL NPI NUMBER