Provider Demographics
NPI:1295788867
Name:GOULD, TIMOTHY D (EDD LPC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:GOULD
Suffix:
Gender:M
Credentials:EDD LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 S KINGSHIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-4415
Mailing Address - Country:US
Mailing Address - Phone:573-979-3676
Mailing Address - Fax:
Practice Address - Street 1:903 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4415
Practice Address - Country:US
Practice Address - Phone:573-979-3676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002646101Y00000X
MOCS002646101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431823864OtherMISSOURI ALLIANCE
MO11-3764474OtherMAGELLAN
420291OtherHEALTHLINK/FREEDOM
MO493840714Medicaid
49906211OtherEPOCH
420291OtherFORTIS/HL
431823864OtherCORPHEALTH
156007OtherBLUE CROSS BLUE SHIELD
431823864OtherGREATWEST
MO311575142Medicaid
420291OtherHEALTHLINK PPO
MO100387OtherVETERANS ADMINISTRATION
431823864OtherMULTIPLAN
431823864OtherWELLPOINT