Provider Demographics
NPI:1629597208
Name:GOSSETT, AMY LOUISE (PSYD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LOUISE
Last Name:GOSSETT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LOUISE
Other - Last Name:GAINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:6431 BRANDO LOOP
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-3764
Mailing Address - Country:US
Mailing Address - Phone:916-532-5191
Mailing Address - Fax:916-878-4039
Practice Address - Street 1:1660 E ROSEVILLE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3988
Practice Address - Country:US
Practice Address - Phone:916-878-4023
Practice Address - Fax:916-878-4039
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29328103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical