Provider Demographics
NPI:1972518645
Name:GOUGUET, MARILYN L SR (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:L
Last Name:GOUGUET
Suffix:SR
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 W CANAL ST
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3918
Mailing Address - Country:US
Mailing Address - Phone:601-749-9477
Mailing Address - Fax:601-889-1265
Practice Address - Street 1:703 W CANAL ST
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3918
Practice Address - Country:US
Practice Address - Phone:601-749-9477
Practice Address - Fax:601-889-1265
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC22031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124987Medicaid