Provider Demographics
NPI:1134569890
Name:GOOCH, MITCHELL BENJAMIN
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:BENJAMIN
Last Name:GOOCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2580 CHUCKANUT ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97408-7327
Mailing Address - Country:US
Mailing Address - Phone:503-269-4979
Mailing Address - Fax:
Practice Address - Street 1:2580 CHUCKANUT ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97408-7327
Practice Address - Country:US
Practice Address - Phone:503-269-4979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0134196101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR101YM0900XOtherMENTAL HEALTH