Healthcare Provider Details

I. General information

NPI: 1386245710
Provider Name (Legal Business Name): JOHN EDWARD GOUGH MHP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 11/03/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 COLONIAL DR BLDG 200A
COLUMBIA SC
29203-6818
US

IV. Provider business mailing address

114 WATERVILLE DR
COLUMBIA SC
29229-8141
US

V. Phone/Fax

Practice location:
  • Phone: 803-898-4850
  • Fax:
Mailing address:
  • Phone: 803-865-8439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: