=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922406420
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY GOULD LSAA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2014
-----------------------------------------------------
Last Update Date | 12/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 SILVER AVE SE STE. F
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87108-2748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-255-1804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3402 SMITH AVE SE APT B
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87106-2559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-715-7314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 0157661
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------