Provider Demographics
NPI:1386245710
Name:GOUGH, JOHN EDWARD (MHP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:GOUGH
Suffix:
Gender:M
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WATERVILLE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-8141
Mailing Address - Country:US
Mailing Address - Phone:803-865-8439
Mailing Address - Fax:
Practice Address - Street 1:2715 COLONIAL DR BLDG 200A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6818
Practice Address - Country:US
Practice Address - Phone:803-898-4850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20048848Medicaid