Provider Demographics
NPI:1710705876
Name:GOLD, MIKE ED
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:ED
Last Name:GOLD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5560 LIBRARY LN APT 106
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1976
Mailing Address - Country:US
Mailing Address - Phone:309-642-1116
Mailing Address - Fax:
Practice Address - Street 1:3225 INTERNATIONAL CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3161
Practice Address - Country:US
Practice Address - Phone:309-642-1116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0021273101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health