MEDICARE: IAN BRODERICK GOUGH MS, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor
2	101YP2500X	Professional Counselor	178018226	IL

General Provider Information

NPI Number	:	1568134625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN BRODERICK GOUGH MS, LPC

Provider Business Mailing Address
First Line	:	1616 N DAMEN AVE UNIT 301
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5536
Country	:	US
Telephone Number	:	888-303-2844
Fax Number	:

Provider Business Practice Location Address
First Line	:	1616 N DAMEN AVE UNIT 301
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5536
Country	:	US
Telephone Number	:	888-303-2844
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2021
Last Update Date	:	04/24/2023

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