Provider Demographics
NPI:1073949806
Name:HOUGHBROOK, GUSSIE P
Entity Type:Individual
Prefix:
First Name:GUSSIE
Middle Name:P
Last Name:HOUGHBROOK
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 1:2501 HIGHWAY 60 E
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33567-3829
Mailing Address - Country:US
Mailing Address - Phone:813-737-1335
Mailing Address - Fax:
Practice Address - Street 1:2501 HIGHWAY 60 E
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33567-3829
Practice Address - Country:US
Practice Address - Phone:813-737-1335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL141476300Medicaid