MEDICARE: STEPHANIE GOLD PHD

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	103TC0700X	Clinical Psychologist	0005212	CO

General Provider Information

NPI Number	:	1326670605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE GOLD PHD

Provider Business Mailing Address
First Line	:	66 MILBURN LN
Second Line	:
City	:	ROSLYN HEIGHTS
State	:	NY
Zip	:	11577-1514
Country	:	US
Telephone Number	:	516-406-1757
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 GARDEN CITY PLZ STE 400
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-3332
Country	:	US
Telephone Number	:	516-406-1757
Fax Number	:

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

Provider Enumeration Date	:	02/05/2020
Last Update Date	:	02/05/2020

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