MEDICARE: CKG PSYCH INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	6301016590	MI
2	103TC0700X	Clinical Psychologist	6301016590	MI

General Provider Information

NPI Number	:	1013469410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CKG PSYCH INC

Provider Business Mailing Address
First Line	:	628 E PARENT AVE
Second Line	:	SUITE 202
City	:	ROYAL OAK
State	:	MI
Zip	:	48067-3765
Country	:	US
Telephone Number	:	510-214-2544
Fax Number	:

Provider Business Practice Location Address
First Line	:	628 E PARENT AVE
Second Line	:	SUITE 202
City	:	ROYAL OAK
State	:	MI
Zip	:	48067-3765
Country	:	US
Telephone Number	:	510-214-2544
Fax Number	:

Authorized Official
Title or Position	:	OWNER/LICENSED PSYCHOLOGIST
Name	:	DR. CORIE GOULD
Credential	:	PSY.D.
Telephone Number	:	406-698-2722

Provider Enumeration Date	:	11/01/2016
Last Update Date	:	11/01/2016

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Directions to “CKG PSYCH INC ” Practice Location

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