Basic Information
| Provider Information | |||||||||
| NPI: | 1295749786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOULET | ||||||||
| FirstName: | MARGUERITE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MA LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 617 OAK ST | ||||||||
| Address2: | |||||||||
| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564013610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188297140 | ||||||||
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| Practice Location | |||||||||
| Address1: | 617 OAK ST | ||||||||
| Address2: | |||||||||
| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564013610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188297140 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1885 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6234637 | 01 | MN | MEDICA | OTHER | 848977 | 01 | MN | ARAZ | OTHER | 62G73GO | 01 | MN | BCBS | OTHER | 115668 | 01 | MN | UCARE | OTHER |