Healthcare Provider Details

I. General information

NPI: 1336673623
Provider Name (Legal Business Name): ALETHEA GOUGH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 W EVERGREEN AVE STE 404
CHICAGO IL
60642-7113
US

IV. Provider business mailing address

917 N FAIRFIELD AVE # 3
CHICAGO IL
60622-4454
US

V. Phone/Fax

Practice location:
  • Phone: 312-242-1665
  • Fax:
Mailing address:
  • Phone: 815-501-7861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149017983
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: