Provider Demographics
NPI:1922406420
Name:GOULD, GREGORY (LSAA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:GOULD
Suffix:
Gender:M
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3402 SMITH AVE SE
Mailing Address - Street 2:APT B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2559
Mailing Address - Country:US
Mailing Address - Phone:505-715-7314
Mailing Address - Fax:
Practice Address - Street 1:4300 SILVER AVE SE
Practice Address - Street 2:STE. F
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2748
Practice Address - Country:US
Practice Address - Phone:505-255-1804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0157661101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor