Healthcare Provider Details

I. General information

NPI: 1073935631
Provider Name (Legal Business Name): CONNIE M. GOULD LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2729 GUN CLUB RD SW
ALBUQUERQUE NM
87105-6331
US

IV. Provider business mailing address

2729 GUN CLUB RD SW
ALBUQUERQUE NM
87105-6331
US

V. Phone/Fax

Practice location:
  • Phone: 505-363-2901
  • Fax:
Mailing address:
  • Phone: 505-363-2901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0887
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: