Provider Demographics
NPI:1366637001
Name:GOOCH, ELLEN AMMEN (MSW)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:AMMEN
Last Name:GOOCH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-6103
Mailing Address - Country:US
Mailing Address - Phone:910-374-9225
Mailing Address - Fax:
Practice Address - Street 1:93 GARDEN DR
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-6103
Practice Address - Country:US
Practice Address - Phone:910-374-9225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY077240101YS0200X
NC0772401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical