Healthcare Provider Details

I. General information

NPI: 1528205994
Provider Name (Legal Business Name): MARY M GOUGH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 SPRING ST
PLACERVILLE CA
95667-4543
US

IV. Provider business mailing address

929 SPRING ST
PLACERVILLE CA
95667-4543
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-6303
  • Fax:
Mailing address:
  • Phone: 530-621-6303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number93472
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: