Provider Demographics
NPI:1740428325
Name:NALLY, MAUREEN GOUGH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:GOUGH
Last Name:NALLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BROOKMERE CT
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-2604
Mailing Address - Country:US
Mailing Address - Phone:201-665-9818
Mailing Address - Fax:
Practice Address - Street 1:920 48TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2918
Practice Address - Country:US
Practice Address - Phone:718-283-7890
Practice Address - Fax:718-283-6161
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017944-1103TP2701X, 103TH0004X, 103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral