Provider Demographics
NPI:1124128657
Name:LEVICK GOLD, JOAN M (PHD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:LEVICK GOLD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 118
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12037-0118
Mailing Address - Country:US
Mailing Address - Phone:518-392-7314
Mailing Address - Fax:518-392-5764
Practice Address - Street 1:7 THOMAS RD
Practice Address - Street 2:
Practice Address - City:VALATIE
Practice Address - State:NY
Practice Address - Zip Code:12184-4321
Practice Address - Country:US
Practice Address - Phone:518-392-7314
Practice Address - Fax:518-392-5764
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009681-1103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01905259Medicaid
NY01416751Medicaid
NY009681-1OtherJOAN'S LICENSE
NY133586OtherVALUE OPTIONS JOAN
NYV3A951Medicare ID - Type UnspecifiedDOWNSTATE JOAN
NY01905259Medicaid
NYVOW561Medicare ID - Type UnspecifiedDOWNSTATE GROUP
NY133586OtherVALUE OPTIONS JOAN