Provider Demographics
NPI:1063288215
Name:GOOCH, CONNOR
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:GOOCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 ROCKHILL CIR
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-7359
Mailing Address - Country:US
Mailing Address - Phone:573-855-6370
Mailing Address - Fax:
Practice Address - Street 1:3003 E CHESTNUT EXPY STE 800
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-6311
Practice Address - Country:US
Practice Address - Phone:573-855-6370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021047666101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional