MEDICARE: MADELINE RUTH GOULD JD, MSW, LCSWA

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	2084P0802X	Addiction Psychiatry Physician	200500827	NC
2	1041C0700X	Clinical Social Worker	P018055	NC

General Provider Information

NPI Number	:	1053045542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELINE RUTH GOULD JD, MSW, LCSWA

Provider Business Mailing Address
First Line	:	305 SILENT MEADOW CT
Second Line	:
City	:	WAXHAW
State	:	NC
Zip	:	28173-6869
Country	:	US
Telephone Number	:	704-641-1367
Fax Number	:

Provider Business Practice Location Address
First Line	:	640 SUMMIT CROSS PLACE
Second Line	:	SUITE 203
City	:	GASTONIA
State	:	NC
Zip	:	28054
Country	:	US
Telephone Number	:	704-237-4240
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2022
Last Update Date	:	07/28/2022

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