Healthcare Provider Details

I. General information

NPI: 1508532466
Provider Name (Legal Business Name): AZALEAH GOOSE APCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2903 SACRAMENTO ST
BERKELEY CA
94702-2509
US

IV. Provider business mailing address

490 LAKE PARK AVE UNIT 10694
OAKLAND CA
94610-8025
US

V. Phone/Fax

Practice location:
  • Phone: 510-269-7726
  • Fax:
Mailing address:
  • Phone: 510-269-7726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPCC11952
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: