Provider Demographics
NPI:1366281461
Name:GOULD, LAQULISHA DENISE
Entity type:Individual
Prefix:
First Name:LAQULISHA
Middle Name:DENISE
Last Name:GOULD
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 1:4553 DELTA FAIR BLVD APT A12
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-3955
Mailing Address - Country:US
Mailing Address - Phone:510-228-6036
Mailing Address - Fax:
Practice Address - Street 1:22050 WOODROW AVE
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541
Practice Address - Country:US
Practice Address - Phone:510-613-0330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
CA172V00000X
CA4600572443172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health