Healthcare Provider Details

I. General information

NPI: 1497633051
Provider Name (Legal Business Name): ANTHONY GOUGE PPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 BLACKROCK DR
SACRAMENTO CA
95835-1250
US

IV. Provider business mailing address

PO BOX 19055
SACRAMENTO CA
95819-0055
US

V. Phone/Fax

Practice location:
  • Phone: 916-928-5353
  • Fax:
Mailing address:
  • Phone: 916-821-4645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number220002073
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: