Provider Demographics
NPI:1871819177
Name:GOUGH, BETHANY HARRELSON (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:HARRELSON
Last Name:GOUGH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 E COUNTY LINE RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1928
Mailing Address - Country:US
Mailing Address - Phone:601-853-9747
Mailing Address - Fax:601-898-4761
Practice Address - Street 1:950 E COUNTY LINE RD
Practice Address - Street 2:SUITE E
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1928
Practice Address - Country:US
Practice Address - Phone:601-853-9747
Practice Address - Fax:601-898-4761
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3346235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist