Provider Demographics
NPI:1801407317
Name:SHARON R. GOUGH GRIEF AND TRAUMA THERAPY PC
Entity Type:Organization
Organization Name:SHARON R. GOUGH GRIEF AND TRAUMA THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:GOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC, LCDC
Authorized Official - Phone:575-590-0238
Mailing Address - Street 1:1204 MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-8000
Mailing Address - Country:US
Mailing Address - Phone:575-590-0238
Mailing Address - Fax:
Practice Address - Street 1:880 PROSPECTOR TRL STE 100
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-2700
Practice Address - Country:US
Practice Address - Phone:254-690-1512
Practice Address - Fax:254-690-1532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1750554374Medicaid