Provider Demographics
NPI:1851460521
Name:GOUGH, HEATHER ROBYN (MSW, JD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ROBYN
Last Name:GOUGH
Suffix:
Gender:F
Credentials:MSW, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 N TEXAS ST
Mailing Address - Street 2:SUITE 440
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-1290
Mailing Address - Country:US
Mailing Address - Phone:707-580-5781
Mailing Address - Fax:707-429-1307
Practice Address - Street 1:2750 N TEXAS ST
Practice Address - Street 2:SUITE 440
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-1290
Practice Address - Country:US
Practice Address - Phone:707-429-4440
Practice Address - Fax:707-429-1307
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW 207281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical