Healthcare Provider Details

I. General information

NPI: 1013469410
Provider Name (Legal Business Name): CKG PSYCH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 E PARENT AVE SUITE 202
ROYAL OAK MI
48067-3765
US

IV. Provider business mailing address

628 E PARENT AVE SUITE 202
ROYAL OAK MI
48067-3765
US

V. Phone/Fax

Practice location:
  • Phone: 510-214-2544
  • Fax:
Mailing address:
  • Phone: 510-214-2544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301016590
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6301016590
License Number StateMI

VIII. Authorized Official

Name: DR. CORIE GOULD
Title or Position: OWNER/LICENSED PSYCHOLOGIST
Credential: PSY.D.
Phone: 406-698-2722