=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205976255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH L. GOLD PSY.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 04/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 412 EXECUTIVE DR
-----------------------------------------------------
City | LANGHORNE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19047-8003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-968-3338
-----------------------------------------------------
Fax | 215-968-2456
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 412 EXECUTIVE DR
-----------------------------------------------------
City | LANGHORNE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19047-8003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-968-3338
-----------------------------------------------------
Fax | 215-968-2456
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSO15331
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------