Provider Demographics
NPI:1790029866
Name:GOUGH, BEVERLY (MA CCC SLP)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:GOUGH
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 W BIG BEAVER RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3501
Mailing Address - Country:US
Mailing Address - Phone:248-816-7000
Mailing Address - Fax:248-928-0523
Practice Address - Street 1:1635 W BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3501
Practice Address - Country:US
Practice Address - Phone:248-816-7000
Practice Address - Fax:248-928-0523
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6744-SL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist