Provider Demographics
NPI:1174021182
Name:CARNOCHAN, GOUVERNEUR M
Entity Type:Individual
Prefix:
First Name:GOUVERNEUR
Middle Name:M
Last Name:CARNOCHAN
Suffix:
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 1:10 FUNSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94129-1109
Mailing Address - Country:US
Mailing Address - Phone:415-793-6511
Mailing Address - Fax:
Practice Address - Street 1:10 FUNSTON AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94129-1109
Practice Address - Country:US
Practice Address - Phone:415-793-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15189103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist