Provider Demographics
NPI:1508513904
Name:GOUCK, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GOUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19543-8814
Mailing Address - Country:US
Mailing Address - Phone:484-888-1101
Mailing Address - Fax:
Practice Address - Street 1:555 SECOND AVE STE B-300
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-3636
Practice Address - Country:US
Practice Address - Phone:484-938-8461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-05
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
PAPC015080101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health