1962705814 NPI number — MS. JACQUELYN SUSAN GOULD LISW-S

Table of content: MS. JACQUELYN SUSAN GOULD LISW-S (NPI 1962705814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962705814 NPI number — MS. JACQUELYN SUSAN GOULD LISW-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOULD
Provider First Name:
JACQUELYN
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LISW-S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962705814
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22001 FAIRMOUNT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNIVERSITY HEIGHTS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44118-4819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-320-8315
Provider Business Mailing Address Fax Number:
216-320-6446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22001 FAIRMOUNT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY HEIGHTS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44118-4819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-320-8315
Provider Business Practice Location Address Fax Number:
216-320-6446
Provider Enumeration Date:
12/15/2010

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: 1041C0700X , with the licence number:  I-0005692 SUPV , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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