Provider Demographics
NPI:1528103546
Name:GOUGH, DEREK MARK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:MARK
Last Name:GOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:GOUGH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:224 EAST ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PITTSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27312-9750
Mailing Address - Country:US
Mailing Address - Phone:919-542-0747
Mailing Address - Fax:
Practice Address - Street 1:224 EAST ST
Practice Address - Street 2:SUITE A
Practice Address - City:PITTSBORO
Practice Address - State:NC
Practice Address - Zip Code:27312-9750
Practice Address - Country:US
Practice Address - Phone:919-542-0747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2369101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103515Medicaid