Healthcare Provider Details

I. General information

NPI: 1639342421
Provider Name (Legal Business Name): AMY LYNN GOULD LPCC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3659 GREEN RD STE 101
BEACHWOOD OH
44122-5715
US

IV. Provider business mailing address

3659 GREEN RD STE 101
BEACHWOOD OH
44122-5715
US

V. Phone/Fax

Practice location:
  • Phone: 216-401-7433
  • Fax: 855-860-1978
Mailing address:
  • Phone: 216-401-7433
  • Fax: 855-860-1978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.0602179-SUPV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.0602179
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE0602179 SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: