Provider Demographics
NPI:1326311309
Name:GOLD, PETER (MA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:GOLD
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 NE 12TH AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407 NE 12TH AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2752
Practice Address - Country:US
Practice Address - Phone:503-806-9680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health