Provider Demographics
NPI:1255879045
Name:GOUSE, BETH (PHD)
Entity type:Individual
Prefix:DR
First Name:BETH
Middle Name:
Last Name:GOUSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1489 CHAIN BRIDGE RD
Mailing Address - Street 2:203
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-5724
Mailing Address - Country:US
Mailing Address - Phone:703-505-3163
Mailing Address - Fax:
Practice Address - Street 1:1489 CHAIN BRIDGE RD
Practice Address - Street 2:203
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-5724
Practice Address - Country:US
Practice Address - Phone:703-505-3163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002067103T00000X
DCPSY1775103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist