Provider Demographics
NPI:1356486153
Name:GOOCH, PENELOPE JEAN (MS LP)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:JEAN
Last Name:GOOCH
Suffix:
Gender:F
Credentials:MS LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 W SUPERIOR ST STE 400
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1726
Mailing Address - Country:US
Mailing Address - Phone:218-740-3026
Mailing Address - Fax:218-740-3030
Practice Address - Street 1:324 W SUPERIOR ST STE 400
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1726
Practice Address - Country:US
Practice Address - Phone:218-740-3026
Practice Address - Fax:218-740-3030
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3676103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN535S1N0OtherBCBS
MN805716800Medicaid
MN6245819OtherMEDICA UBH