Provider Demographics
NPI:1790994309
Name:GOTTFRIED, MICHAEL GS (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GS
Last Name:GOTTFRIED
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14377 WOODLAKE DR STE 315
Mailing Address - Street 2:
Mailing Address - City:TOWN AND COUNTRY
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5735
Mailing Address - Country:US
Mailing Address - Phone:314-304-3707
Mailing Address - Fax:
Practice Address - Street 1:14377 WOODLAKE DR STE 315
Practice Address - Street 2:
Practice Address - City:TOWN AND COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63017-5735
Practice Address - Country:US
Practice Address - Phone:314-304-3707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002021877103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist