Provider Demographics
NPI:1558979518
Name:GOULD, STEPHANIE LEIGH (MA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LEIGH
Last Name:GOULD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-6191
Mailing Address - Country:US
Mailing Address - Phone:847-529-8300
Mailing Address - Fax:
Practice Address - Street 1:122 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-6191
Practice Address - Country:US
Practice Address - Phone:847-529-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000724106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist