Provider Demographics
NPI:1861214777
Name:GOULD, MIRANDA S (LSW #0009925525)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:S
Last Name:GOULD
Suffix:
Gender:F
Credentials:LSW #0009925525
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 MOHAWK DR APT B6
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-3742
Mailing Address - Country:US
Mailing Address - Phone:858-208-8377
Mailing Address - Fax:
Practice Address - Street 1:777 29TH ST STE 500
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2357
Practice Address - Country:US
Practice Address - Phone:720-551-8074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0009925525104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker