Healthcare Provider Details

I. General information

NPI: 1497091490
Provider Name (Legal Business Name): LEROYAL TERRELL GOULD III MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2012
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3332 BRIDGES ST STE A
MOREHEAD CITY NC
28557-3296
US

IV. Provider business mailing address

3332 BRIDGES ST STE A
MOREHEAD CITY NC
28557-3296
US

V. Phone/Fax

Practice location:
  • Phone: 252-726-9006
  • Fax:
Mailing address:
  • Phone: 252-726-9006
  • Fax: 252-726-4325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC009106
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: