Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 BANCROFT AVE STE 267
OAKLAND CA
94605-2408
US

IV. Provider business mailing address

PO BOX 1085
RICHMOND CA
94802-0085
US

V. Phone/Fax

Practice location:
  • Phone: 510-735-0864
  • Fax: 510-746-1196
Mailing address:
  • Phone: 510-269-7726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPCC11952
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPCC11952
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPCC11952
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: