Provider Demographics
NPI:1548775232
Name:GARDNER-GOULD, CASSIE MIKAILA
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:MIKAILA
Last Name:GARDNER-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 1:4524 TUJUNGA AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2040
Mailing Address - Country:US
Mailing Address - Phone:763-639-8571
Mailing Address - Fax:
Practice Address - Street 1:4940 VAN NUYS BLVD STE 201
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1700
Practice Address - Country:US
Practice Address - Phone:818-985-0560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)