Provider Demographics
NPI:1407417256
Name:GOUGH, ANEETRIA (BCBA)
Entity Type:Individual
Prefix:
First Name:ANEETRIA
Middle Name:
Last Name:GOUGH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 S DILLWYN RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-5549
Mailing Address - Country:US
Mailing Address - Phone:215-500-5771
Mailing Address - Fax:
Practice Address - Street 1:231 S DILLWYN RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-5549
Practice Address - Country:US
Practice Address - Phone:215-500-5771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005364103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst