Healthcare Provider Details

I. General information

NPI: 1457085037
Provider Name (Legal Business Name): TIM DUANE GOUGH JR. LCSW-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2022
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E CECIL AVE STE B
NORTH EAST MD
21901-4057
US

IV. Provider business mailing address

102 E CECIL AVE STE B
NORTH EAST MD
21901-4057
US

V. Phone/Fax

Practice location:
  • Phone: 667-231-1269
  • Fax:
Mailing address:
  • Phone: 667-231-1269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number28745
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: