Provider Demographics
NPI:1134978877
Name:GOLD, TIKVA
Entity type:Individual
Prefix:
First Name:TIKVA
Middle Name:
Last Name:GOLD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 N LINDBERG ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-2120
Mailing Address - Country:US
Mailing Address - Phone:219-702-7186
Mailing Address - Fax:
Practice Address - Street 1:442 N LINDBERG ST
Practice Address - Street 2:
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-2120
Practice Address - Country:US
Practice Address - Phone:219-702-7186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL37807101YA0400X
IL041.183107163W00000X, 163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No163W00000XNursing Service ProvidersRegistered Nurse