Healthcare Provider Details

I. General information

NPI: 1730305079
Provider Name (Legal Business Name): KELLY ANN GOULD LCMHC, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 TW ALEXANDER DR. SUITE 124 #172
MORRISVILLE NC
27560-6815
US

IV. Provider business mailing address

2121 TW ALEXANDER DR. SUITE 124, #172
MORRISVILLE NC
27560-6815
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: --
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11413
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5521
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: