Healthcare Provider Details

I. General information

NPI: 1134569890
Provider Name (Legal Business Name): MITCHELL BENJAMIN GOOCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 CHUCKANUT ST
EUGENE OR
97408-7327
US

IV. Provider business mailing address

2580 CHUCKANUT ST
EUGENE OR
97408-7327
US

V. Phone/Fax

Practice location:
  • Phone: 503-269-4979
  • Fax:
Mailing address:
  • Phone: 503-269-4979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0134196
License Number StateVT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: