Basic Information
| Provider Information | |||||||||
| NPI: | 1558697458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOUGH | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | RUTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12458 JULIAN AVE | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920404141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6199722020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2049 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | LEMON GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919454221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194657303 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2009 | ||||||||
| LastUpdateDate: | 10/27/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.