Provider Demographics
NPI:1184890204
Name:GOULD, PETER
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:GOULD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10615 JUDICIAL DR
Mailing Address - Street 2:102
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-7501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10615 JUDICIAL DR
Practice Address - Street 2:102
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7501
Practice Address - Country:US
Practice Address - Phone:703-346-0837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003885103TC0700X, 103TB0200X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent