Provider Demographics
NPI:1043921356
Name:MCGOUGH, JULIETTE MARIE
Entity Type:Individual
Prefix:
First Name:JULIETTE
Middle Name:MARIE
Last Name:MCGOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 STONEY WAY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-1845
Mailing Address - Country:US
Mailing Address - Phone:916-606-9658
Mailing Address - Fax:
Practice Address - Street 1:4811 CHIPPENDALE DR STE 208
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-2551
Practice Address - Country:US
Practice Address - Phone:916-638-2508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC53992224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter