Provider Demographics
NPI:1316228638
Name:GOULD, BLYTHE C
Entity Type:Individual
Prefix:MISS
First Name:BLYTHE
Middle Name:C
Last Name:GOULD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-3206
Mailing Address - Country:US
Mailing Address - Phone:802-324-4233
Mailing Address - Fax:
Practice Address - Street 1:2145 DIAMOND HILL RD
Practice Address - Street 2:SUITE A
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-5135
Practice Address - Country:US
Practice Address - Phone:802-324-4233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-31
Last Update Date:2013-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC00591101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health