Provider Demographics
NPI:1891389722
Name:GOUGH, MARISSA JORDYN
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:JORDYN
Last Name:GOUGH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:JORDYN
Other - Last Name:BOURGEOIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 SEQUOYAH LN
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-1756
Mailing Address - Country:US
Mailing Address - Phone:580-379-0203
Mailing Address - Fax:
Practice Address - Street 1:111 SEQUOYAH LN
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-1756
Practice Address - Country:US
Practice Address - Phone:580-379-0203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11721101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor