Provider Demographics
NPI:1124042833
Name:GOUCHER, PAMELA ANN (LCSW)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:ANN
Last Name:GOUCHER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:ANN
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:5 CLYDE LN
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72715-4312
Mailing Address - Country:US
Mailing Address - Phone:901-604-1057
Mailing Address - Fax:
Practice Address - Street 1:5 CLYDE LN
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72715-4312
Practice Address - Country:US
Practice Address - Phone:901-604-1057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11151041C0700X
AR1528-C1041C0700X
AR1528C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5U641Medicare ID - Type Unspecified