Provider Demographics
NPI:1346024411
Name:GOUDGE, TROY DANIEL
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:DANIEL
Last Name:GOUDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5980 S DURANGO DR STE 131
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-1775
Mailing Address - Country:US
Mailing Address - Phone:866-505-1376
Mailing Address - Fax:
Practice Address - Street 1:5980 S DURANGO DR STE 131
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-1775
Practice Address - Country:US
Practice Address - Phone:866-505-1376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT3462106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician