1194078568 NPI number — MRS. ELLEN GOLD MPS, BCDMT, LPC

Table of content: MRS. ELLEN GOLD MPS, BCDMT, LPC (NPI 1194078568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194078568 NPI number — MRS. ELLEN GOLD MPS, BCDMT, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLD
Provider First Name:
ELLEN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPS, BCDMT, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YACOE
Provider Other First Name:
ELLEN
Provider Other Middle Name:
GOLD
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1194078568
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11726 LARIAT LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22124-2323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-860-8188
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11726 LARIAT LANEE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-860-8188
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  37PC00234600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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