Provider Demographics
NPI:1316963382
Name:GOULD, SHANNON (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:GOULD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 WELLS ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-1200
Mailing Address - Country:US
Mailing Address - Phone:518-930-4615
Mailing Address - Fax:518-930-4715
Practice Address - Street 1:7 WELLS ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-1200
Practice Address - Country:US
Practice Address - Phone:518-930-4615
Practice Address - Fax:518-930-4715
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016788103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02814482Medicaid
NY02814482Medicaid