Healthcare Provider Details

I. General information

NPI: 1154928976
Provider Name (Legal Business Name): ANA-ALICIA GOUGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 HUDSON LN
MONROE LA
71201-6003
US

IV. Provider business mailing address

10080 HIGHWAY 129
MONTEREY LA
71354-4606
US

V. Phone/Fax

Practice location:
  • Phone: 318-322-6500
  • Fax:
Mailing address:
  • Phone: 504-451-2734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: