Provider Demographics
NPI:1194788695
Name:GOFF, GORDON CLYDE (LCSW)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:CLYDE
Last Name:GOFF
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13138 COUNTY ROAD 79
Mailing Address - Street 2:
Mailing Address - City:FLEMING
Mailing Address - State:CO
Mailing Address - Zip Code:80728-9644
Mailing Address - Country:US
Mailing Address - Phone:970-265-3052
Mailing Address - Fax:
Practice Address - Street 1:219 S 4TH ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:CO
Practice Address - Zip Code:80751-4233
Practice Address - Country:US
Practice Address - Phone:970-466-9074
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9917591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO66836Medicare ID - Type Unspecified