Provider Demographics
NPI:1427180470
Name:GOUIN, MYRANDA MARIE
Entity type:Individual
Prefix:MISS
First Name:MYRANDA
Middle Name:MARIE
Last Name:GOUIN
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 1:382 FINCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-8612
Mailing Address - Country:US
Mailing Address - Phone:209-484-3973
Mailing Address - Fax:
Practice Address - Street 1:382 FINCHWOOD DR
Practice Address - Street 2:
Practice Address - City:LATHROP
Practice Address - State:CA
Practice Address - Zip Code:95330-8612
Practice Address - Country:US
Practice Address - Phone:209-484-3973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW16765101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional