Provider Demographics
NPI:1871316547
Name:GOLD, JAY EZRA (LICSW, LADC)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:EZRA
Last Name:GOLD
Suffix:
Gender:X
Credentials:LICSW, LADC
Other - Prefix:
Other - First Name:J
Other - Middle Name:
Other - Last Name:GOLD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW, LADC
Mailing Address - Street 1:520 OSBORNE RD NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2718
Mailing Address - Country:US
Mailing Address - Phone:763-236-4579
Mailing Address - Fax:763-236-4370
Practice Address - Street 1:520 OSBORNE RD NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2718
Practice Address - Country:US
Practice Address - Phone:763-236-4579
Practice Address - Fax:763-236-4370
Is Sole Proprietor?:No
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306430101YA0400X
MN132021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)