Provider Demographics
NPI:1891015608
Name:GOUGH, DIANE LAURA (MFT)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:LAURA
Last Name:GOUGH
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 CHANNEL ISLANDS DR
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-9180
Mailing Address - Country:US
Mailing Address - Phone:805-279-7160
Mailing Address - Fax:
Practice Address - Street 1:841 CHANNEL ISLANDS DR
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-9180
Practice Address - Country:US
Practice Address - Phone:805-279-7160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT15882106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist