Provider Demographics
NPI:1073704961
Name:GOUGE, GAYLA M (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:GAYLA
Middle Name:M
Last Name:GOUGE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 S PINE AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5211
Mailing Address - Country:US
Mailing Address - Phone:918-852-9148
Mailing Address - Fax:
Practice Address - Street 1:11740 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-1820
Practice Address - Country:US
Practice Address - Phone:918-437-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical