Provider Demographics
NPI:1770724924
Name:GOLD, AMY CAROL (MA; LMFT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:CAROL
Last Name:GOLD
Suffix:
Gender:F
Credentials:MA; LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 WILLOW ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2269
Mailing Address - Country:US
Mailing Address - Phone:612-872-2343
Mailing Address - Fax:360-233-0649
Practice Address - Street 1:1409 WILLOW ST
Practice Address - Street 2:SUITE 600
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2269
Practice Address - Country:US
Practice Address - Phone:612-872-2343
Practice Address - Fax:360-233-0649
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-18
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLMFT1146106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNM488355100OtherMEDICAL ASSISSTANCE
MNM488355100Medicare UPIN
MNM488355100OtherMEDICAL ASSISSTANCE