MEDICARE: MR. DOUGLAS ALLAN GAUSS LCSW

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	1041C0700X	Clinical Social Worker	IP 608	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3006330	OTHER	TN	BCBSTN

General Provider Information

NPI Number	:	1629062278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS ALLAN GAUSS LCSW

Provider Business Mailing Address
First Line	:	PO BOX 344
Second Line	:
City	:	BRUNSWICK
State	:	TN
Zip	:	38014-0344
Country	:	US
Telephone Number	:	901-872-3525
Fax Number	:	901-872-2610

Provider Business Practice Location Address
First Line	:	7864 HARROLD CV
Second Line	:
City	:	MILLINGTON
State	:	TN
Zip	:	38053-2400
Country	:	US
Telephone Number	:	901-872-3525
Fax Number	:	901-872-2610

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

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	07/08/2007

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