Provider Demographics
NPI:1720150691
Name:GOULD, TYLER JAMES (PHD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:GOULD
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 1:1 KENNEDY DR
Mailing Address - Street 2:SUITE U8
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7152
Mailing Address - Country:US
Mailing Address - Phone:802-864-4513
Mailing Address - Fax:802-878-1903
Practice Address - Street 1:1 KENNEDY DR
Practice Address - Street 2:SUITE U8
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7152
Practice Address - Country:US
Practice Address - Phone:802-864-4513
Practice Address - Fax:802-878-1903
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048-0000788103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT28635OtherBLUE CROSS BLUE SHIELD VT
VT1007391Medicaid
VT1007391Medicaid