Provider Demographics
NPI:1093752453
Name:GOUGH, CECILE (LMSW)
Entity Type:Individual
Prefix:
First Name:CECILE
Middle Name:
Last Name:GOUGH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-3602
Mailing Address - Country:US
Mailing Address - Phone:316-660-7600
Mailing Address - Fax:316-383-7925
Practice Address - Street 1:934 N WATER ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-3838
Practice Address - Country:US
Practice Address - Phone:316-660-7525
Practice Address - Fax:316-383-4590
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS793104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS389913OtherBLUE CROSS BLUE SHIELD
KS9431OtherPREFERRED HEALTH SYSTEMS