Provider Demographics
NPI:1154096527
Name:GOUSSAK, ASHLEY ROSE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ROSE
Last Name:GOUSSAK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-686-4444
Mailing Address - Fax:
Practice Address - Street 1:9834 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1223
Practice Address - Country:US
Practice Address - Phone:858-626-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030803235Z00000X
CASLP33713235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist