Basic Information
| Provider Information | |||||||||
| NPI: | 1679631949 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOULD | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23210 CHAGRIN BLVD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168316466 | ||||||||
| FaxNumber: | 2167666083 | ||||||||
| Practice Location | |||||||||
| Address1: | 23210 CHAGRIN BLVD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168316466 | ||||||||
| FaxNumber: | 2167666083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2084P0805X | 35036148 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 000000345557 | 01 | BLUE CROSS SHIELD | OTHER | 880908 | 05 | OH | MEDICAID |