Provider Demographics
NPI:1679234827
Name:GOULDER, ALLYSSA (MA)
Entity Type:Individual
Prefix:
First Name:ALLYSSA
Middle Name:
Last Name:GOULDER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:ALLYSSA
Other - Middle Name:
Other - Last Name:KLUTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3260 W BIRCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-4035
Mailing Address - Country:US
Mailing Address - Phone:262-832-4759
Mailing Address - Fax:
Practice Address - Street 1:217 WISCONSIN AVE STE 211
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4946
Practice Address - Country:US
Practice Address - Phone:262-235-0593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-09
Last Update Date:2022-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional