Provider Demographics
NPI:1568760064
Name:GOLD, TERRA (DOM, LAC)
Entity Type:Individual
Prefix:MISS
First Name:TERRA
Middle Name:
Last Name:GOLD
Suffix:
Gender:F
Credentials:DOM, LAC
Other - Prefix:
Other - First Name:TERRA
Other - Middle Name:
Other - Last Name:GOLD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DOM, LAC
Mailing Address - Street 1:1247 7TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1642
Mailing Address - Country:US
Mailing Address - Phone:310-804-2926
Mailing Address - Fax:
Practice Address - Street 1:1247 7TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1642
Practice Address - Country:US
Practice Address - Phone:310-804-2926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
CAAP 2847171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No133N00000XDietary & Nutritional Service ProvidersNutritionist