Provider Demographics
NPI:1568134625
Name:GOUGH, IAN BRODERICK (MS, LPC)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:BRODERICK
Last Name:GOUGH
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 N DAMEN AVE UNIT 301
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5536
Mailing Address - Country:US
Mailing Address - Phone:888-303-2844
Mailing Address - Fax:
Practice Address - Street 1:1616 N DAMEN AVE UNIT 301
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5536
Practice Address - Country:US
Practice Address - Phone:888-303-2844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IL178018226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor